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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 -I- I r7 Z .S City 6101 Lot Size PM I-.__ Owner's Name �/� [/�/[.G! Address Phon 9- Q 3 3 1 Contractor cl1- +f„I Address'__)-X43 z License Phon 3 7- $ '/ TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION'' SYSTEM REPAIR ❑ OTHER CI DISTANCE TO NEAREST: SEPTIC TANK -1420_ SEWER-LINES DISPOSAL FLD. /S70 PROP. LINE 3- FOUNDATION FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing WDomestic/Private )lii1Gravel Pack ❑ Tracy Type of Casing-,4-7y4c Specifications f'I Public F I Other (-1 Delta Depth of Grout Seal /O 0 Type of Grout I Irrigation t r-R-.-Approx. Depth I 1 Eastern Surface Seal Installed by CO/-' -►ie !L Repair Work Done ❑ Type of Pump T"12 H,P. Z. State Work Done J' Well Destruction R Well Diameter 4Sealing Material (top 50') C 0-0" f&--r- Depth -r De th-_ S'O i P ... Filler Material (Below 50'l _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I t 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 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 of 4 -- T Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines _ Total length/size FILTER BED El Distance to nearest: Well J Foundation Property Line SEEPAGE PITS l I Depth Size _Number -J SUMPS [�I Distance to nearest: Well Foundation b Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and thauthe 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 not certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall em to tion taws of California." employ persons subject to workman's compensa- The-applicant must call for Il regtyred inspections. Complete drawing on reverse side. Signed X. /��(� # Title. - Date: FO DEPARTMENT USE ONLY � y Application Accepted by Date �- Area Pit or Graut spection by Date .c7l�Final Inspection by Date -2 �v Additional Comments: � -� ( �Q- /JU � '� ✓�� ElStk 466-6781 C1Lodi 369-3621 ❑ Manteca 3-7104 ❑ 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 DUE AMOUNT REMITTED CK RECEIVED BY INFO R DATE PERMIT'NO. EH 13-241REV.1/k51 J p� C; I L4 C4 0 d--b u