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f APPLICATION FOR PERMIT 'A SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CAN M Telephone (209) 466-$781 " 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 an install the work herein described. This application is N made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wellipump,and the Rules and Regulations of the San Joaquin Local Health District. o .2 ro �J . s i�� - �I- City. 5T 63 7d Lot Size PM"— Job Address s O /�a1 14,123, 9 s7 -/�Gco.aLs. 8_2\3 �rr3 Owner's Name Address rz2 9537 Contractor S Address License No. Phone TYPE OF WELL/PUMP: NEW WELL 11 WELL REPLACEMENT F1 DESTRUCTION LI PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. DISPOSAL FLO. PROP. LINE C 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ) ❑ Industrial ❑ Open Bottom b ❑ Manteca --Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 0 4 1-1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout , I I Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by - r w Repair Work Done El Type of Pump. H.P. State Work Done Well Destruction ElWell Diameters Sealing Material atop 501 Depth Filler Material {Below 541 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I.l DESTRUCTION 1No septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence="'""Commercial—.. Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet:r� t ," P { SEPTIC TANK ❑ Type/Mfg " a ity 16.m No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to'nearest.Per v ti may hag, e*xpii e� W(�� ��*��oOrAroperty Line kirw LEACHING LINE ❑ No. & Length of line t •ViWangth/size FILTER BED ❑ Distance io nearest: I+VeI Foundation Property Line i� SEEPAGE PITS I 1 Depth I Size Number ,t SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r; 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. i 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 persons subject to workman's compensa- tion laws of California." .I The applicant must call for all required inspections. Complete drawing on rev se side. Signed Title: Date: .67 .F "EP ARTMENT USE ONLY Application Accepted by Date 177 Area U Pit or Grout Inspection by Data Final Inspection by Date ��7 r` Additional Comments:22 �n ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 a Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 FEE AMOUNT DUEAMOUNT REMITTED K RECEIVED,BY DATE PERMIT"NO. INFO p -y 'p)g) + EH13-24IRT7 J EV.I/K5Y � ]�f 7- •✓,30 EH 1 4-28 d