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APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT - ' 1601 E. HAZEL T ON AVE., STOCKTON, CA �r Telephone (209) 466-6781 ; � _ PERMIT EXPIRES T YEAR FROM DATE ISSUED W--33 37 —Z-9 t (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 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 JP City Lot Size PM COwner's Name / � ^-� � "' Addresst'- /C� _ p +Y?honer �'�y� Contractor --�Adtlress.'`r] ,Eti.P ®B/,rlyicense No.-W( / Phone TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ ! DESTRUCTION L} 1 PUMP INSTALLATION SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ya SEWER LINES `� DISPOSAL FLD---I—LO;KJ 705PROP. LINE x FOUNDATION;- AGRICULTURE WELL _ 07HER WELL PITS/SUMPS ��C3 f _ lINTENDED USEvTYP �� 4 �r E OF WELL PROBLEM AREA CONSTRt1CTION SPECIFICATIONS r. ❑ Industrial 00 )Cbpen Bottom ❑ Di Manteca a- of Well Excavation Dia. of Well Casing Domestic/Private C Gravel Pack LJ Tracy Type of Casing Specifications f� 16 t1 Public ! Ll Other 17 Delta Depth of Grout Seal p Type of Grout g6�9%1 I 1 Irrigation ; Approx. Depth I II Eastern Sutrf ce Sed Installed by 5Z f2M" I Repair Work Done ❑ Type of �u�mp—StA IS H.P. _ L��-- �'+ State Work Done -01 Well Destruction ❑ Well,Diameter- Sealing Material (top 50')? j f u�,.Depth _ Filler Material (Below 50'l; L I r [� f TYPE OF SEPTIC WORK-A NEW INSTALLATION I] REPAIR/ADDITION (.I DESTRUCTION i I (No septic system permitted if public sewer is -tom available within 200 feet.) # l j`- I Installation will serverResiBencb=yCbmrllerci01-' Other Number of living units: Number of bedrooms Character of soil to/ depth of 3�feet" 'p x ^. •, F * x Water table depth 4 SEPTIC TANK L7 T ► p ype/Mfg pa6ty'; No. Compartments PK6.4REATMENT PLT, ❑ { r �01Method of pisposal r r Distance to nearest: Well Foundation r Property Line LEACHING U*NE `► ❑ No. & Length of lines W I Total length/size If 4 FILTER BED,, ❑ Distance to nearest: Well Foundation-; r Property Line SEEPAGE PITS f I Depth Si Number , SUMPS f 1 Distance to Barest: Well FqundationProperty T Line t DISPOSAL PONDS ❑ - • TL-- 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 certify that in the performance mance of the work for which this permit is issued, I shall no employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this per tion laws of California." mit is issued, I shall employ persons subject to workman's compensa The applicant t I for all required i ctio omplete drawing on reverse e. Signed X ` _ Title: �'�_�� Date: � t t € tom= FOR DEPARTMENT USE ONLY Application Accepted by Pit or Grout Inspection by Date Final Inspection by °� Ir 4 Dates g, . Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 C7 Tracy 835- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave:, P.O. Box 2009, Stk., CA 95201 a^ t FEE AMOUNT DUE AMO NT REMITTED CK § INFO CASH RE16EIVED 9Y DATE PERMIT'Np. r EH 13-24 IREV, t/H5) 41 EH 14-2e �✓ O�. Q ��y l