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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �. 1601 E. HAZELTON AVE., STOCKTON, CA �. Telephone (209) 466-6781Q PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. t Job Address City `s Lot Size Z �� / PM Owner's Name k' ,Al- 1 MO Cen Address /��5,fAC r - Phone 366—OSf Phone Contractor Q t timp Address ��P>�PG License No. TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ . PUMP INSTALLATION JLl pro I \� I SYSTEM REPAIR ❑! OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES 10DISPOSAL FLD. PROP. LINE X01 FOUNDATION DI AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / S/ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing b 1}KDomes1i.c Pnate Gavel Pacrk ❑ racy _ Tyjie`af C sing - e - -- 1—Specifications ('I Public 0 Othef { ❑ Delta Depth of Grout Seal ype of Grout I I Irrigation �& AApprox.};Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump Sri, H.P. } State Work pone Well Destruction ❑ Well Diameter Sealing Material.ftop 501 ` Y k Depth r Filter Material (Below 50') !t TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I l iNo septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence= Commercial_ Other Yom: ��-cam , t r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:` t Water table.depth SEPTIC TANK ❑ Type/Mfg Capacity I .17'°n` No. Compartments = PKG. TREATMENT PLT:❑ 1 Method of Disposal — f Distance to nearest: Well Foundation i . Property Line LEACHING LINE .❑ No. & Length of lines Total length/sizes FILTER BED t D—Distance to nearest: Well Foundation j PropertyLine 1� SEEPAGE PITS I I I Depth Size Number SUMPS ❑ 'Distance to nearest: Well Foundation t Property Line' t* ~� DISPOSAL PONDS,•w O—+ I hereby certify that I have prepared this application and that the work will be dorie in accordannce with San Joaquin county ordinances, state laws, and rules and regulations of the San J ao quiet Local Health District" l } Home owner or licensed agent's signature certifies-the-following: "I certify that'in the performance of the work for which this permit is issued, I shall not E employ any person in such manner as to become subject to workman's-compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applican st call_for all requi ed irtspe "o s. Complete awing on reverse side. T — — ,.r ^^ a Signed X Title: � �_-_ Date: R DEPARTMENT_ USE ONLY y 1[ C{ Application Accepted by Date 0' C1 P, AZ - V 1 Pit o ro Inspection b Oates` Final Inspection by Date10, J Additional Comments:Q " .✓ ��%��f�✓�� —;,4/ ��GG.�� 1of11�'f%lyG�� e '-tea 171Stk 466-6781 odQ+C i 369-.3621 ❑ Manteca 823-71 racy �5-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INE 1}t1A0UNT DUE AMOUNT REMITTED CK CEIVED BY TE PERMiT N � +.EH 13-244-28 EV,r i N 5Y P A�• �' rQ 6 7 EH 1