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Y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA NoU Telephone (209) 466-6781 1 PERMIT EXPIRES TYEAR FROM DATE ISSUED IWO b (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 i 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 � / p 1 City J y� Lot Size ly PM i Owner's Name /� C,/C��3/C�nI Address s..WV cc. (/ Q l n/ Phone X6 Contractor a� ♦7 Address.-Yet f !�` gqC-. License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ [ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ If DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE PITS/SUMPSFOUNDATION AGRICULTURE WELL� OTH INTENDED USE TYPE OF WELL PROBLEM AREA CONST SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy = ''°Type of Casing Specifications k y i 1 Public aa.FI-Other � n Deltas,,,,,..",4W.Depth of.Grout Seal, Type.of Grout _ N I I Irrigation � -�-Approxs. Depth I I Eastern Surface Seal Installed bye` _ r -- - -. - - Repair Work D _❑„rrcType of PumR _`_ H•P"' State Work Done Well uction ❑ Well Diameter Sealing Material ('top50'1 r Depth Filler Material (Below 50') ' 1 TYPE OF SEPTIC WORK: NEW INSTALLATION i l REPAIR/ADDITION i,_) DESTRUCTION (No septic system permitted if public sewer is J 6 available within 200 feet.) Installation will serve: ' Residence I Commercial_ Other A. , Number of living units: NumLber of bedrooms Character of soil toga 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 Total length/size-l' s FILTER BED ❑ Distance to nearest: Well Foundation Property Line -I i 1 SEEPAGE PITS I 1 Depth ' Size Number SUMPS t L7 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS L. ❑ 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 fegulations of the San Joaquin Local Health District:" ' "'' "-----'M 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." E ,_Thle'applj ani must call for apreuired ins tions. C mplete drawing on reverse side. r ,e% Signed Title: ,r Date: "' 141_q7 ZEPARTMENT USE ONLY i Application Accepted byL Date j^ Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 C1 Manteca 823-7104 ❑ Tracy 835-63.95 Applicant- Return all copies to: Environmental Health,Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CK^-H RECEIVED BY DATE PERMIT'NO. + EH 13-24'IREV.I i H 5) V rr CLQ R11 l� 1 EH 1428 ri: