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a 1� APPLICATION`FOR PERMIT } SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA t' Telephone 12091 466-6781 PERMIT EXPIRES VYEAR FROM DATE ISSUED i (Complete in Triplicate) F 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 F 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. k[ Job Address rrjCity 521! Lot Size r-' PM I � � Owner's Name Address b �- 22-, Phone Contractor, License Na/4 2_3 7 3 Phone TYPE OF WELL/PUMP: NEW WELL 5;-- WELL REPLACEMENT ❑ rDESTRUCTION ❑ PUMP INSTALLATION Q�e' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC.TANK /00 " SEWER LINES 1s6 DISPOSAL FLD. PROP, LINE-_1'_'!!;!L FOUNDATION (3p r AGRICULTURE WELL " OTHER WELL PITS/SUMPS] INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �f ❑ Industrial ❑ Open Bottom ❑ Manteca . Dia. of Well Excavati Dia. of Well Casing Onomestic/Private R"Gravel Pack ❑ Tracy Typo of Casing Specifications F1 Public F1 Other F1 Delta Depth of Grout Seal O0 Type of Grout r- i I Irrigation —_Approxi Dept I I Eastern S ace Seal Installed by od Repair Work Done ❑ Type of Pump H,P. State Work Done. Well Destruction ❑ Well Diamete Sealing Material (top 501 / Depth Filler Material (Below 501 , TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is t /available within 200 feet.) '^ Installation will serve:'-Residence Commercial— Other ' i 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 Distance to nearest: Well Foundation Property Line 4 LEACHING LINE ❑ No-&_Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t i SEEPAGE PITS I I Depth ' T Size Number + SUMPS Ll Distance to nearest: Well Foundation Property Line 1 DISPOSAL PONDS ❑ 1 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 6er4y that lin theperformance of the work for which this permit is issued, I shall not employ any'person in such manner as to became 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 applica ust all for I rerjuir inspection . Complete drawing o arse side. Signed X Title: M 2 ^� Date: FOR DEPARTMENT USE ONLY Application Accepted by bate (Q-�� -� 7 _Q�J _ rea Pit or Grout Inspection by ate a�/' �p t? Final Inspection b Additional Comments: c-A l�L)0 1)1 �c.4-7'opl❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 y 835-6385 nice 1- LOU( f l�a Applicant - Return all copies to: Environmental Health Permit/Services 1.601 E. Hazelton Ave., P.O.'Box 20K Stk., CA 95201 7 , i FEE CK I F INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. j . EM 13-24 1REV,t i x 51 I _ / 2 ( EH 14.26, lllJJl�✓ ts� v '7---)l