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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 r (Complete in Triplicate) i 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. J �� - p f� Job Address 92I�7 tl d '�'A _ _ City Lot Size/09 PM IF Owner's Name AddresS'9/i7,jet/ o d - !p ?"-' 7gZaPhone 31J 440 Contractor&-_41L gL d4l Address ei'7b"1 __License No. 32Y7-2-K— Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Priv ate Pack ❑ y Type of Casing Specifications Public f� Delta Depth of Grout Seal Typeof GroutI 1 Irrigationro epth I 1 Eastern Surface Seal Installed by Repair Work Donump H.P. State Work DoneWell Destructioneter Sealing Material (top 50'1 Filler Material (Below 50') TYPE OF SEPTTC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_X_ Commercial Other Number of living units: _/__ Number of-bedrooms Character of soil to a depth of 3 feet: Water table depth t C c � SEPTIC TANK - M'�'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 Depth Size Number _:F2 SUMPS ^� Cl Distance to nearest: Well '1"oundation Property Line DISPOSAL PONDS ❑ 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 Diktrict. — I '_ 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 r all required inspecti Complete drawing on 'reverse side. / fr Signed X Title: Date:Ll /�•, fT7 `ice m FDR-DEPA MENT USE-.ONLY.. 3 �fC�r Application Accepted by Date Area r g /} Pit r Grout Inspection by f DateFinal Inspecti n by a3 2?Gls..�X Date a "A ditional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mainteca 823-7104 ❑ racy 835-695 Applicant - Return.all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMIT'NO. s EH 14-A V.t i K 57 ENq 1A-28 r `v S