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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELI ON AVE., STOCKTON, CA Telephone (709) 466-6781 I 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. ? Job Address ck 179w7go City Lot Size/ / J r PM Owner's Name!.J'amg S(rr /197 pf-sjg Addre lk5ab 24%4 Phone9e/ 72 s Contractor / Address License No. I�e Phone lfs TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ A T r~ ,....DISTANCE TO-NEAREST: SEPTIC TANK,-/B0_ '� / � SEWER LINES. /Co�---'�'-� - .DISPOSAL FLD Q4"' PROP'LINE°�e FOUNDATION 2S / . AGRICULTURE WELL OTHER WELL;PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavra'�tio''nI /f �"�' Dia. of Well Casing X Domestic/Private Gravel Pack El Tracy Type of Casing�C_. Specifications cia,Ss 160 ❑ Public ❑ Oi er L Delta at Depth of Grout Seal >/ Type of Grout �1 Ll Irrigation f�Approx. Depth r'❑ Eastern' Surface Seal Installed by Repair Work Done ❑ Type of Pump, ' H.P,:" � t j State Work Done Well Destruction -❑ Well Diameter Sealing.Material (top 501 Depth Filler Material (Below"50')- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑b(No septic system permitted if public sewer is available within 200 feet.( - Installation will serve: Residence_ Commercial_ Other t j E Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ` r Water table depth SEPTIC TANK ❑ Type/ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: ell Foundation Property Line i LEACHING LINE ❑ No. & Leng of lines Total length/size I FILTER BED 71Distan to nearest: Well Foundation Property Line SEEPAGE-PITS " ❑ ..Depth = Size r Y�� '_ _ -_Number- SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS . 1-11 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." The applicantpust call for all required inspe tions. Complete drawing on reverse side. d Signed Title: _ C C7 iia oy _ Date: L -� ^/�vT-r DEPARTMENT USE ONLY p Application Accepted by Date I\_ZL Area Pit or Grout Inspection by Date 169,9 PkI Final Inspection by A>" _ Date d-ate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 389-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 � Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2DD9, Stk., CA 95201FEE ' e INFO AMOUNT DU'E'T AMOUNT REMITTED CASK J RECEIVED BY ) 1DGAiTE PERMIT'LN�O.. + EH13.24(REV.I/a5) �� - V .S. t //moo,`./_�7�j f� 3/ 7V EH 1428 ! r -3l