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�J APPLICATION FOR PERMIT 4 1 SAN JOAQUIN LOCAL HEALTH DISTRICT +il f 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 r 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. /, F Job Address �7gno nL. 1 & City Lot Size h-/ if G45 ply 12�219�107<_fC_12 Owner's Name -.SA�f'l En In0 Q) Q9 Address U Phone oa Yy)f)f )til P(knlp,-�S P Contractor Address License No-(!� ¢4 _ -D�� Phone_ -A TYPE OF WELL/PUMP; NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION -SYSTEM ,,.-��REPAIR 171 OTHER ❑ 9 DISTANCE TO NEAREST: SEPTIC TANK ♦ O SEWER LINES -�.LO t_ DISPOSAL FLD 7 PROP. LINE c22AX FOUNDATION � AGRICULTURE WELL/_1!N0__ OTHER WELL PITS/SUMPS llJr1/s`�, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f �/ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation�_ Dia. of Well Casing � CD omestic/Private Gravel Pack Ll Type of Casing_ cV F,[_!. Specifications i`l Public 11 Other Ll Delta Depth of Grout Seal Type of Grout I Irrigation 1 X� p/prox. Depth i I EasterntSurface Seal installed by ` Repair Work Done ( Type of Pump _�f'Y�_ H•P. ._/at _ State Work Done _ i Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRIADDITION 1.1 DESTRUCTION l I (No septic system permitted if public sewer is available within 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 Distance to nearest: Well Foundation Property Line ( LEACHING LINE ❑ No: & Length of lines f 9 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS Ll Distance to nearest: Well ^Foundation Property Line DISPOSAL PONDS ❑ I 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 Diltrict. Home owner or licensed agent's signature certifies the followings"1 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: "!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 applicartt�m t call for"all required inspecti ris. Complete dr wing on rse side. �] Signed it Bate: FOR DEPARTMENT USE ONLY I� f Application Accepted by A0 Date ea PitoGrou Inspection by Datq/�Final Inspection b Date Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 -* "'FEE —AMOUNT' Ci [NFO AMOUNT REMITTED RECEIVED BY DATE - PERMIT'NO. r.EH 13-24IREV.t/n51 j � Jr' �* + �T.._.. EH 14.20 i L < CLS .r " 'ter