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VW APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED mg )?X4— (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 C6unty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.' Jab Address 55001 JN V L City 95 Lot Size PM Owner's Name Address -T--- i Phone S L; Contractor ' - Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARE=ST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS © Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavations Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public n Other CI Defta D pth of Grout Seal i p - - t, p � Type of Grout I I Irrigation �.-Approx. Depth I 1 Eastern Surface Seal Installed by f Repair Work Done ❑ Type of Pum �. YP F p H. State Work Done q Well Destruction ❑ Well Diameter . Sealing Mateiial (top 50 Depth i I Filler Material{Below 50') _ _I TYPE OF SEPTIC WORK: NEW INSTALLATION•d,l.--REPAER/ADDITI.. -I-L•.-DESTRUETfo -Wo-septic system permitted if public sewer is f vailabWwithin 200 feet.) Installation will serve: Residence Comrbercial_ Other' r Number of living units: ' Number of bedrooms Character of soil to a depth of 3 feet.I f f f Water table depth SEPTIC TANK ❑ I Type/Mf ' ' t PKG. TREATMENT PLT. ❑ g Capacity=- No. Compartments Method'-of Disposal Distance-to nearest: Well Foundation Property Line yy� LEACHING LINE ❑ No- & LtAglth of linesr Il Total length/size FILTER BED ❑ Distance to nearest: , Well Foundation Property Line'1 - SEEPAGE PITS I'I Depth Size Number " 1 SUMPS Ll Distance to nearest: Well Foundation ,Property Line � CPI DISPOSAL PONDS ❑ y , p I hereby certify that I have prepared this application rid 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.ttie folEowin l certify that in the `"- r ,� employ an r g' fY performance of the work for whicFi this permit is issued, 1 shall not i p y y person in such manner as to become subiect to workman's compensation laws of California."Contractor's hifing or sub-contracting signature certifies th following: "I certify that in'the performance of the work for which this permit is issued, I shall employ persons.$ubject to workman's compensa- tion laws o Califomia." #_ a - f- The applica must call for all required inspections. Complete drawing on reverse side. Signed X ' - ..Title: '� �— ""`r ! Date: - i OR DEPARTMENT USE ONLY Application Accepted by Date ! Area Pit or Grout Inspection b I Y , Date Final Inspection by ate Q Additional Comments: — � y - ❑ Stk 466-6781 ❑ Lodi 368-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE CK INFO t AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. " + EH 13-24 IREV.5 i n 51 ��00 J7 � (52 r EH 14-26 1`^fl"�!% -IL r