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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2091466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICOmplete 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. v Job Address ..101//.�iti /Em�� 10A / City .S e Lot Size—. PM Owner's Name ,�/fll �J/l �Cj� ,p �C rens X l/OZ,i �.��1/9 Phone 7P�-Z/pm Contractor��'F.Uri%l' ./ cv est s 36�J'' Oie.'M liters rC a 4/1..x... i 9S7S�2 TYPE OF_ W=LL/PUMP. N WE License No.�rte_rwy�irhone iG WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP I LA ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC / OTHER K '��'�`� SEWER LINES 'PR FOUNDATif /!,', DISPOSAL FLD. PROP. LINE AGRICULTURE WELL 07HER WELL INTENDED USE TYPE OF WELL PITS/SUMPS _ PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Domestic/Private ❑ Manteca Dia. of Well Excavation -/.cc'.( ❑ Gravel Pack ❑ TracV Dia. of Well Casing F- F) Public ❑ Other Type of Casing /EioNF Specifications I Delta Depth of Grout Seal 4 %K ,6 Tv I I Irrigation ?L,Approx. Depth I I Eastern Typa of Grout iA� ❑ Type of P Repair Work Done Surface Seal Installed by aii Pump H.P. _ Well Destruction ❑ Well Diameter 4!57 State Work Done_ Depth Z a Sealing Material (top 501) p Filler Material (Below 501 ,TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is Installation will serve: ResidenceCommercial_ Other available within 200 feet.) 1 Number of living units: __ Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity No. Compartments `1 Distance to nearest: Well Method of Disposal V Foundation Property Line LEACHING LINE LI No. & Length of lines FILTER BED ❑ Distance to nearest: WellTotal length/size Foundation party Line SEEPAGE PITS I I Depth SUMPS Size N r L1 Distance to nearest: Well DISPOSAL PONDS ❑ Foundation ropeny Line I hereby certify that I have prepared this application and that the work will be done in ac rdan istrict. Home owner or licensed a ant's signature certifies the following: h San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Dg g g: "I certify that in th or of the work for which this permit is issued, I shall not P Y any person in such manner as to become subject to workman's com ensatio ws o alifornia."Contractor's hiring or sub-contracting signature certifies the following: emto "I certify that in the performance of the work for which this Perm tion laws of Californian P d, I shall employ persons subject to workman's compensa- The applicant must call for�Il required inspections. Complete drawing on reverse side. _ Signed �� Title: f�U%K• `Z- Date: /F R DEPARTMENT USE ONLY Application Accepted by ji/,✓/ gg G, Data — ( o Area `133 Pit or Grout Inspection by Date Final Inspection by Additional Comments: Date ❑ 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 FEE gMOUNT DUE INFO AMOUNT REMITTED E RECEIVED BY • EN 1344 REV.rix6i on N DATE PERMIT NO. EH 14-M 1 �) o o.T�e