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%me APPLICATION FOR PERMIT *awd SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E HAZELTON 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 Haft District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance MD.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ¢*AQ��/ ' ;�L 1�r, gym, Lot Size PM Owner's Nam�e��/��reywle/�s/�c/jC0� �r� _ ,�.JPy � / 1`�1 Phone e�-o""d Contracttxl _6��a't T/ � Address — cS /g�2.� _ License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Er' ' SQ�✓1 .I.IR/ DISTANCE TO NEAREST: SEPTIC TANK L5.-1 SEWER LINES Aad 7' DISPOSAL FLD. PROP. LINE FOUNDATION 5<f) AGRICULTURE WELL14::�-1 OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y y O ❑ Industrial ❑ Open Bottom ❑ Maflteca Dia. of Well Excavation Dia. of Well Casing dO1 ❑ Domestic/Private ❑ Gravel Pack AeTraq Type of Casing Specifications ❑ Public j2lother ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth 9 Easaan Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter - Sealing Material(top 50) TPEOF SEPTIi �tl Depth Filler Material IBelow 50') TYPE OF - ORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 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: 14k8 Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wli Foundation Property Line r SEEPAGE PITS ❑ Depth Sias Number SUMPS ❑ Distance to nearest: Wall Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and 00 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 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 w workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of to work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all r uired inspeytions. Corn*te drawing on reverse side. — �y/ � --••,,,, 7 Signed X /�� C.X�"-"�' Title: Date: —�� FOR DEPARTMENT USE ONLY Application Accepted by ��"��" `- p �- I 1—9.5I Arae 17 Ph or Grout In / on �.5�/T Inspection by Final Inspection by pare N Additional Comments: /tea/� '{ti� -.";- ❑ Stk 466-6781 ❑ Lodi 3011-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6306 cant- Return all res�/Environme ty�Heahh Servi 180) Hazelton A ., P.O. �sI tk., CA 1 INFO AMOUNT DUE AMOUNT I�/6atirED �At�BH R�EyC�EIVED BY Q DATE p� PQERMIT NO. ♦aR 13.N IflEV.t I a s) �:>� :.s, y3,oa /F77 IYJ —/—�3-0.1 Q.S'1(17 BI 1438