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APPLICATION FOR PERMIT `C 57, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 No PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) 4-t-_ 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. . Job Address .5"d� !U_ ,S/� R�R_ .L�[/ City sem,✓ Lot Size 3rV X 1 o PM Owner's Name GE1Vn/ 19• C.4^P.62 Address 4 fj(o Z,0 .. �.!eJ .-_ Phone Contractor F4-0Y_D_ _--, LJ9Pep Address D -.2 .45 License No.SAY. 7 Phone 4-6. 347 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES tSPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Ma ca Dia. of Well Excavation Dia. of Wel! Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications i`l Public Fl Other Ll Delta Depth of Grout Sea! Type of Grout _ I I Irrigation _.Appro epth l I Eastern Surface Seal Installed by Repair Work Done E Type of ump H,P. State Work Done Well Destruction ❑ Wel iameter Sealing Material Itop 50'1 Depth Filler Material (Below _ TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION lI ESTR CTION IND se is system permitted if public sewer is availa a 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: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS Cl 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, an 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 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 for all required inspections. Complete drawing on reverse side. Signed X Title: &Zr�l _ Date: —9 O R DEPARTMENT USE ONLY + C, Application Accepted by Date 3`b— l Area (, Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IEEE AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT-NO. ♦ EH 13-24 1REV.s/"51Sf-f EH 14.26 CJ 4