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r . APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 Cbunty 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 :2 /Oo!Er 5ZA70 !�AL12 _..._ City Lot Size / 1 C PM � r�• 1 Owner's Name l t� f' yam, Address Phone _ M C1 vyytt�s Contractor/—, G' Di v' "Z// Address Q A719 �� /Pl icense No. 6�J49 Phone�7/ TYPE OF WELL/PUMP:- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ROP. LINE FOUNDATION AGRICULTURE WELL 0 LL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CO ION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack acy Type of Casing Specifications i'] Public l7 Other I ❑ Delta Depth of Grout Seal Type of Grout V) 11 Irrigation - pproxf Depth I 1 Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done rte. Well Destr - n ❑ Well Diameter Sealing Material (top 501 --------------- 1 Depth Filler Material {Below 50') ` TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION ! I (No septic system permitted if public sewer is IV available within 200 feet) Installation will serve: Residence z Commercial I Other' Number of living units: Number of bedrooms 3 f �C " I x _ Character of soil to a depth of 3 feet. S�N�y Qui_- Water table depth" SEPTIC TANK ❑ Type/Mfg GO&e-lee Capacity 12f ©_ No. Cornpartrrients PKG. TREATMENT PLT. ❑ �-- /. / " 'Method qf.Dis�p sal Distance to nearest: Well Foundation Property Lined LEACHING LINE ❑ No. & Length of,lines otal lengtWsize• FILTER BED s - I Distance to nearest: sf#,Wall_`_�_. Fouundatjpn Pr party Llne- # - g y SEEPAGE PITS 11 Depth Size *��/�'C�b"e N_ umber SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ '•xr I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqui cn aunty ordinances, state laws, and I IP rules and regulations of the San Joaquin Local Health District. ' 4 Home owner or licensed agent's signature certifies the following: "I certify thaiin 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 compel tion laws of California." + S nsa- T a plicant call for all required inspectiops. Complete drawing on reverse side. Signed X Title: i --/'a Date: RTMENT USE ONLY Application Accepted by Date Area Ag�Pit or Grout Ins ! pection by date `X t Final!lnspection by Additional Comments: y ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies io: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a FEE AMOUNT DUE AMOUNT REMITTED CK INFO f RECEIVED BY DATE PERMITNO. + EH13-24PIEV,r/H51 y �jr/ � ' 0 A {.- EH 14-29 • �� ✓� f '3 4.