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APPLICATION FOR PERMIT 1c, _ S, SAN JOAQUIN LOCAL HEALTH DISTRICT ,tJo Pi r,5 1601 E. HAZELTON AVE., STOCKTON, CA C1/VV/,6 Telephone (209) 466-6781PERMIT 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 4v[J6P //. p eq City✓ Lot Size PM Owner's Name �12 4-yD E� /z�!/-7,*%lEr,�SAddress SQ y"' Phone -e S��r Contractor rl-O J�D 6. l(lddD Address 7.y A72d-_C_,E3e5.0-i AUW License No. 5�a��7G Phone 4444-2971 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SE R LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGR ULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE CONST ION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 1-1 Manteca of Wel{ Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy pe of Casing Specifications `l Public ❑ Other ❑ De De th of Grout Seal Type of Grout I Irrigation --Approx. Depth Eastern Surfa Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Weil Diameter Sealing Material (top Depth Filler Material (Below 50'I j TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DE RUCTION iNo septic ystem permitted if public sewer is 0 available ithin 200 feet.) Installation will serve: Residence Commercial_ Other 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. ❑ Method of Disposal r Distance to nearest: Well Foundation Property Line 4 LEACHING LINE ❑ No. & Length of lines Total length/size /'? FILTER BED El Distance to nearest: Well Foundation Property Line V` SEEPAGE PITS i I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 Di§trict. 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." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: L; _ Date: Z 9a DEP ENT USE ONLY Application Accepted by . Q ,.— ��Rz �J11l�M4.-_, Date 1-9 Area ' 3/70 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT NO. + EH 1 -24 IREV.t i H 5) '-9 EH 14-2e 1 l