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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 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 i made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City �C_ Lot Size � pry 1 s Owner's Name �a� K1.,e zZe-a Address _� .sr Phone Contractor _ Address _ _ Lice /,/No s, Phone <—. h , TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ V DESTRUCTION ❑ ¢ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS 'INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 1 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Welt Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac T e of Casin _- �- y yp g _ `-Specifications M Public s +r ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation i r --Approx. Depth { I Eastern Surface Seal Installed by Repair Work Done Y ❑ Type of Pump H.P. StateWork Done_ 1 Well Destruction I t �❑ Well Diameter i r Sealing Material (tap 50'I ,� € Depth Filler Material (Below 50') TYPE OF SEPTIC WORK; NEW INSTALLATION iW REPAIR/ADDITION (.I DESTRUCTION i 1 (No septic sysiem permitted if public sewer is ~� available within 200 feet.) Installation will senrre: Residence Commercial— Other f r t ` Number of living units: _!— Number of bedrooms hi i , Character of soil to a depth of 3 feet: D Water table depth I SEPTIC TANK I ❑ Type/Mfg '. 1 Cap city t Nd. PKG. TRCcimparthients r r.EATMENT PLT. ❑ Y �s, Method of Disposal f l Distance to nearest; Well L�1020 Foundation k • _f0 LProperty Line t ! d_1 LEACHING LINE itti ' No. & Length of lines Total'e th�size AJC? FILTER BED # ❑ Distance to nearest: Weil_/t,J-T �/lj,�� `'�- '� '� Foundation Property..Linep�7 SEEPAGE PITS i I Depth Size ,Number •:` SUMPS r _ , ❑ Distance to nearest: Well Foundation` Pro eri 'L"ine ' .YY. i DISPOSAL PONDS r ❑ �'' :. � I hereby certify that 1 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.., `e `.'•z s Home owner or licensed agent's signature certifies the following: "I certify thatin,the'performance of the wdrk:for which this permit is issued,,I shall not empfay any person in such manner as to become subject to workman;s compensation laws of California."Contractor's hiring or sub-contracting sign9f re 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 applicant must call for all equir d inspections. Complete drawing on reverse siders----• --w•--- -t'- Signed X t , Title: _: _��_ Date- FOR DEPARTMENT USE,GNLY Application Accepted by Date I IF Area l i Pit or Grout Inspection by Date Final Inspection Date € � 1 � S Addition I Comments: ❑ Stk -6781 D Lodi 369-3621 M nteca 823-7104 Tracy 835-6385 ! Applicant- Retdrn all copies to: Environmental Health Permit/Servicas 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 FEEt . .._ _CK. ' F INFO AMOUNTI]UE _ AMOUNT REMITTED r- RECEIVEp$Y QATE�-w. PERMI7'Nd. .. _. CASH ry ♦.EH 13-24 EH 11-28 } (� IF