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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 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 /2--Z _,- City ! Lot Size / PM Owner's Name Vy &i=& Address l _ � Phone Contractor_ Sm— Address `tea _ F License Na.30S ? Phone 3683 TYPE OF WELL/PUMP:,,_NEW WELL,❑_TM-may _WELL REPLACEMENT❑ _ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑Y OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ;r SEWER LINES DISPOSAL FLD. a PROP. LINE FOUNDATION �j AGRICULTURE WELL OTHER WELL--:,—I PITS/SUMPS INTENDED USE TYPE OF.,WELL PROBLEM AREA CONSTRUCTIONSPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.'of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy' Type of Casing Specifications FI Public i W Other-- ' -F1 Delta Depth of Grout Seal Type of Grout _ i I I Irrigation ,�.-Approx.-Depth { I Eastern � Surface-Seal Installed by _ Repair Work Done ❑ Type of Pump• State Work Done_ 1 e y 1 Well Destruction El � Well Diameter Sealing Material {top 50'1 f F Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIRlADDITION ['DESTRUCTION 11„fNo septic system permitted if public sewer_is—, available within 200 feet.) Installation will serve: I Rersid'ence_� Commercial_ Other Number of living units:�� Number of bedrooms_ f _J Character of soil to a depth of 3 feet: Water table depth Q j SEPTIC TANK 1K Type/Mfg PtmG J�, ,# Capacity No. Compartments PKG. TREATMENT PLT ❑ ' Method of-D�isoslal Distance to nearest: Well 02�� Foundation 10 rep-Property Line;Ly, sa. 1 LEACHING LINE ''_"o.-& Length of lines �? F 0 Total length/size FILTER BED ElDistance to nearest: Well (�.f Foundation 10 f Property Line �119 11 SEEPAGE PITS N . pir 4Size'- _ NumberSUMPS' tance tonearest: 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, 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 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." r The applica .must call for all req ' ed i spections. Complete drawing o9`reverse side. ! I Signed X U' Tit✓ ©�/{kW _ ' Date: l_-� �"2 -00�� F FOR EPARTMENT USE ONLY Applicati Aceepted byDate "' Area orrout Ins orf by ��r� (`�date�z �' inal Inspection by } G�'�l5ate Ir Additional Comments: I I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 : r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED 'CASH, > RECEIVED BY DATE PERMIT NO. +.EH 13-24(ACV.r i H 5) 0 EH 14-2a �� '�.O/