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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA JJJI Telephone (209) 466-6781 ± PERMIT EXPIRES TYEAR 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 QQ� P60 �`' City Lot Size � � PM ' Owner's Name C Address C9- S 1Y Al z, 0 ke'i Phone Contractor b et III LNAddress R,0 AD*'q a 641)r License NoQ 114AVz&�Phone3 'J 3 " 'Tl PE OF`WELL`lPUM111P:" F 'NEW'WEEL' _ - WELL-REPLACEMENT CI -DESTRUCTION--0 --- - ^-� - - PUMP INSTALLATI��OnnN'' ' SYSTEM REPAIR ❑ OO-T.H-,E�R ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLDv ;P .I� ROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL do PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !/ El Industrial pen Bottom [1 Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing----.,7e,e. ! Specifications ('( Public ❑ Other [] Delta Depth of Grout Seal -S7Q Tape 9f G�out.1%Gst[°r+I_ I 1 Irrigation _Approx. Depth I I Eastern S rface Seal Installed by a e- �21�1 t+I_.,.__.., _ Repair Work Done CJ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION [1 REPAIR/ADDITION I I DESTRUCTION ( I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ CommercialV_ Other Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg . Capacity No. Compartments ` PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line r LEACHING-LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE MTS i I Depth Size Number ' SUMPS I ❑ Distance to nearest: Well Foundation Property Line DISPOSALYONDS ❑ - 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. 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:"1 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. Wnplete drawing on reverse side. :Y `�,. vA."�_/ Signed X � r�� AAAA1z}'!\:Title: ��_ Date: FOR DEPARTMENT USE ONLY Application Accepted 16 _Date Area Pit or Grout Inspection by Date 0 f Final Inspection by 14 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. Hazeiton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE r AMOUNT REMITTED CK RECEIVED BY DATE f ERMIT*NO. INFO CASH -71%7 +.EH 13-24 IREV.1/851 l�/19 r7 EH 14-28 / ^` ' t