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APPLICATION.FOR PERMIT A SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a i (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 17'4_ 1,/Y"k City.57Z)6t)2*c/Lot Size PM Owner's Name&. 2 /-e7 Address' Phone Contractor/ olezwze/_V_cSress ,,.3/ 3 ��i� L!//lC0 12`License No. S�& Phone TYPE OF WELL/PUMP: DESTRUCTION PUMP INSTALLATION CN/J�Vl�EYSEEP IRp � OTHER ❑ DISTANCE TO NEAREST_ SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.LI-NE M __ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Man`te�ca —Dia.-of-WeIL.Excavation- Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i Public , ❑ Other ❑ Delta Depth of GAA Seali f Type of Grout )VIrrigation � �`� Approx. Depth ElEastern 5A a.Seal-Installed=by_ Repair Work(' e��`,fype of Pump 77J�@$/A!E_ H.P. ! State Work Done�U Well Destruction ❑ Well Diameter Sealing Material (top 501 e'AWN4—c- Depth `:, Filler Material (R3 low 50') J TYPE OF SEPTIC WORK: NEW INSTALLATION LlREPAIR/ADDITIONI.N DESTRUCTION Ll (No septic system permitted if public sewer is �V 1 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 r 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 ❑` Depth Size Number SUMPS ❑ 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, 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 I 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 mu all or al fired inspections. Complete drawing on ve side. �inI Signed X Title: '!6�/c�5' ( Jl Dew PK, AfUZ � - FOR DE RTMENT USE ONLY �' •f"- Application Accepted by f Date �ZJ '�`at:�-='� Pit or Grout Inspection by Date Final Inspection b �/�!! s1" Date Additional Comments: 0-) I0 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 �.fa '� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952'V FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7'NO. +'EH113-24{REV.}/x 5) +C� -' �_� 1 L EH:14-28 J