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" t 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 a(Complete in Triplicate) I 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 ��'�- City S Lot Size '2 ? 1? PM Owner's Name l,��i1"�'1+ ` � 'Address" 46,9 J� � �\ (�.t _ Phone `�a� ` Contractorddress �/'i` ` — d License No. IV—? phone 372 TYPE OF WELL•/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ` 'ER--❑---- DISTANCE TO NEAREST:, SEPTIC TANK SEWER LINES w 1 I e l Y� DISPOSAL-FLD. IPROR. LINE �'f _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS'/SUMPS I TENDED U,SE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO I It �t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation. Dia, of 1/�/ell Casing ❑ Domestic/Private ❑ Grave ❑ Tracy. Type of Casing - Specification ❑ Public ❑ Other ❑ De Depth of Grout±Seal 'P _ Type of Grout ; ❑ Irrigation �gpprox. Depth ❑ Eastern ~ Surface lied by _ Repair Work Done ❑ Type of Pump H.P. State e Well Destruction ❑ Well OiameY *.�Seafiri M�Cerial(top 5p') r Depth Filler MateIIBelow 50') � y TYPE OF SEPTIC WORK: NEW INSTALLATION In REPAIR/ADDITION,❑`J'DEEYRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) f f Installation will serve: Residence Commercial J OthelLp, n ! Number of living units: Nur#her of bedrooms Character of soil to a depth of 3 fee : Water table depth SEPTIC TANK ❑ Type/Mfg Capacity .(2 _ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposa Distance to nearest:---Wel X61, F6iinda`tia`n J ^"Property L'i`ne 0 ' f tr,/ Zb i LEACHING LINE i�No. & Len th of lines � (lj � g � Total length/size FILTER BED ❑ Distance to nearest: WeJ.l Foundation Property Line t SEEPAGE PITS Depth Size 4 ! SUMPS ❑ Distance to nearest: WeI0kr] � 0 '� f � Foundation , . Property Line DISPOSAL PONDS ❑ r I hereby certify that I have prepared this application and that the work will a 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:folFgwingr,,N'I,c�$itify that in the performance of the work for which this permit is issued, I shall not j employ any person in such manner as to become subject to wo�II`gn's compensation laws of'California." Contractor's hiring or sub-contracting signature f certifies the following: "I certify that in the performance of th ork'tor which thispermit is issued, I shall employ persons subject to workman's compensa- tion laws of California." f' 14 The applican must call for all required inspections. Complete drawing'onreverse sid\ Signed Title: Date: FOR DEPARTME T USE ONLY Application Accepted by �� Area f Pit or Grout Inspection by Date t Final Inspectionliy`� _ Date/1�J Additional Comments: 111 ❑ 5tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104\,, ❑ Tracy 835:�6i85 # Applicant- Return all copies to: Environmental Health Permit/Services-1601 E. Hazelton Ave.,tP.O: Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK :' + INFO CASHf RECEIVED BY _ DATE PERMIT'NO. + EH 13-24(REV:i i•R 5) _ ^-- EH 14-28 L'_7