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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL"HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone 1209) 466-6781 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 Ryles and Regulations of the San Joaquin I. Local Health District. 3 I00 < <- C. F'( r��T if G `�' City'1"� 4_i Job Address Pr Lot Size ` U PM 7 CA yV6' 5''-:. 0!L_ "Ca• Address .?I�o Pr{�Ztx]��{ f}11 CDSTf{ Phone Owner's Nall'-PL = 4 0 Contractor l� GoiZt� Address t`5i X101-D D t1f4��N�a se.'.No.. Phone t ^8 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FUD.— PROP. LINE s FOUNDATION' AGRICULTURE'WELL OTHER WEL'•L '" PITS/SUMPS'— ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.'of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy. Type of Casing UC Specifications d15NJ R&l TV ❑ Public IP'Other i- ❑ Delta Depth of Grout Seal Type of Grout O 'F !T ~ ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Re D O I.r�1a6. S C Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing-Material Itop 50'1 1 # Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is t available within 200 feet.) [ Installation will serve: Residence— Commercial Other f Number of living units: Number of bedrooms Character of soil to a depth of.3 feet:' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' # )Yt Method of Disposal # Distance to nearest: Well Foundation Property Line k LEACHING LINE ❑ No. & Length'of lines Tota! length/size - r FILTER BED ❑ Distance to nearest: I Well Foundation Property Line -SEEPAGE PITS ❑ Depth a ;Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,-state laws, and rules and regulations of the San Joaquin Local Health District. 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 employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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." J` 4 The applicant t call for all required i E ons mplete drawing on reverse side. 1 ti Signed •`�� -"Tifle:'� � � Date: ..fes^.x i D A ME: E ONLY Application Accepted by Date j�k is tri Pit or Grout Ins pe i y (. Date Final Insp ction by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health'Permit/Services f601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT'DUE AMOUNT REMITTED CASH RECEIVED BY,,.,.f DATE PERMIT`N0. INFO + EH 13-241REV,i/B5} - �' a"? �,� .. / '7�FsS ��—174 . EH 1426