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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT W G`- 1601 E. HAZEL 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. I . . i Jab Address f�.J d/ CitylG?'�n� lot Size PM Owner's Name ��J EZ� Al &6V�fIA14 cess 0 ��S7 Phone Contractor--A ., / _ _ Address d 7 License No,r /�,�, '� Phone TYPE OF WELL/PUMP: NEW WELL❑ WELL REPLACEMENT .0 `:` DESTFlUC710N PUMP INSTAL ON ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:, SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION !CULTURE WELL OTHER WELL_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION-SPECIFICATIONS ❑ Industrial .❑ Open Bottom ❑ Manteca ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tra Type o asing Specifications ` 1`1,Public ❑ Other Delta Depth of Gr t Seal Type of Grout I I 1 Irrigation 4.-Appr Depth I I Eastern Surface Seal Inst ed by _ Repair Work Done ❑ Type of Pump H.P. tate Work Done r� Well.Destruction ❑ Well Diameter Sealing Material (tap 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIONX{No septic system permitted if public sewer is lyl available within 200 feet.) Installation will serve: Residence_ Commercial_, Other Number of living units: �p Number of bedrooms r ,} Character of sail to a depth W 3 feet: Water table depth oI SEPTIC TANK ❑ Type/Mfg 1. '""° -- -- Capacity - No_ Compartments O I PKG. TREATMENT PLT:•E _ w, o v. Method o1 Disposal . _' Distance to nearest: Well Foundation Property.Line LEACHING LINE - r ❑ dVo. & Length of lines � Total length/size U, ` i ' FILTER BED.' ❑ Distance to nearest: Well Foundation Property Line G SEEPAGE PITS I 1 Depth Size Number SUMPS C-1 Distance to nearest:. Well Foundation Property Line DISPOSAL PONDS ❑ 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. -v_ 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." The applicant must call f all-quired inspections. Complete drawing on reverse side. Signed Xi� Title: «� . Date: Iw 2RE: LX._ ; Application Accepted by _ bate ^�3 Area 13 Pit or Grout Inspection by I� Date .�^ Final Inspection by / f f Date ` Additional Comments: 6 ❑ Stk 466-6781 fl Lodi 369-3621 ❑ Manteca' 823-7104 ❑ Tracy 835-6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .b..-y- FEE � I�, CK INFO AMOUN�T,,jDUUE AMOUNT,�R-EEMIITTED C . RECEIVED BY DDAT-E� PERMITI,N25 ,O. --� r•EH 13EH14-24IREV.tin51 - 51� - U V+ ✓t `.q/"'S v `L7 �''.'" ^'KJl�5 :i