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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA —� Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 " (Complete jn"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. Job Address 0` Oe` �('G�L/ " /J - "t City Lot Sizet'eDZx PM _ ! .. .. •tAte, .. Owner's Name � Address � r ...,. Phone Contractor +eq � Ree�w r Address �7�p "� � License No y Phone �f=2,6/71,g5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ .� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . AL FLD'/_ PROP. LINE'`-. � �� FOUNDATION AGRICULTURE WE OTHER WELL/' PITS/SUMPS INTENDED USE TYPE-OF WELL PROBLEM AREA ONSTRUCTIQA SPECIFICATIONS` 0 Industrial ❑ Open Bottoms+'ti ,❑ Mante Dia. of Well Exctavation Dia.of'Well Casing Domestic/Private ❑ Grave! Pack ❑ cY ---�Type 6Y Casing i�'t Specifications ❑ Public ❑ Other Delta Depth of Grout Seale ` ' Type of Grout s f❑ Irrigation JAppro� pth ❑ Eastern Surface Seal Installed by'" Repair Work Done ❑ Type o ump H.P. T '`'" State Work Done ,v Well Destruction ❑ Diameter--1 f Sealing Material (top 501 } Depth Filler Material (Below 50')l TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION LJ (No septic system permitted if public sewer is available within 200 feet.) a Installation serve: Residence Commercial— Other ��- .; Number of living units:--4(— Number of bedrooms l - ? Character of soil to a depth of 3 feet: fir- ,y f ` b Dq &!k Water table depth r SEPTIC TANK T e/Mf C�. Cr� f ' yp g Capaci No. Compartments PKG. TREATMENT PLT. ❑ if 'J Method of D' posal ' Distance to nearest: Well "1Foundation /a Property Line lV } # V LEACHING LINE No. & Length of lines 00 Total length/sizeIZQ FILTER BEDS ` ❑ Distance to nearest: . Well 47t -Foundation—If— Property-Line SEEPAGE PITS Depth �� Size OIXVC!! Number SUMPS tz. ❑ Distance to nearest: Well Foundation 3d Property Line t DISPOSAL PONDS ❑ ` 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." 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 peis6n'ssubject to workman's compensa- tion-laws of California." _ The-applicant must I I. r all required ins ns. Complete drawing on reverse side. NI- I �� 2�-�7 Signed Title: ' � Date: r :f FOR DEPARTMENT USE ONLY Application Accepted bye'" `�.DateR- %� Area r #_ f if Grout Inspection by Date � Final Inspection-b Date f� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tra ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. :Box 2009, Stk., CA 95201 P INFO FEE AMOUNT DUE AMOUNT REMITTED ICA SH RECEIVEdBy ` DATES- PERMIT'NO, Y 3 I y � •. r� ..4 4 A f EH13-24(REV.1/e 5) +-.-