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APPLICATION FOR PERMIT F. SAN JOAQUIN LOCAL HEALTH DISTRICT 16/ 1601 E. HAZELTI ON AVE., STOCKTON, CA Telephone (209) 466-6781 W PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ({Complete in Triplicate)" r 'Z--- + �°T., s`,Ps �N 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 i Vo- made in compliance with San Joaquin County Ordinance No.549 for sewage or Na. 1862 for weal/pump and the Ryles and Regulations of the San Joaq�j�1+o Local Health District. {{ ` / 1R1� Ll } L P c t city `- Lot Size 1 X�[ PM! k } Job Address 'a�:zr; hone . . . C \1 J Address - - -- — .- P _ f Owner's Namee } Contra �� x��-� t �-L-Address C �I`�i-icense No. Phone d TYPE OF-WELL/PUMP.."- NEW'WE1C-E3 -WELL REPLACEMENT ❑ DESTRUCTION Q i PUMP INSTALLATION EI SYS7ENI REPAIR C1 OTHER El{ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. : PROP. LINE FOUNDATION AGRICULTURE WELL ^,OTHERWELL PITS/SUMPS r .. Y L INTENDED USE TYPE OF WELL PROBLEM AREA CONLL.STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 3°"""�-❑-Man eco ia. a xca�at�on"T Dia. of Well Casing + ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _ Approx. Depth ❑ Eastern Surface Seal Installed by �� z State Work Done Y Repair Work Done.. ❑ Type of Pump - H.P. Well Destruction ❑ Well Diameter } Sealing Material (top 50') ! f Depth ' J f Filler Material (Below 501 V TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION L3DESTRUCTION ❑ {No septic system permitted if public sewer is j t available within 200 feet.)'- Installation will serve: Residence'Commercial O her ' Number of living units: lot'Number of bedrooms y . .. ho =depod � ^ Vda*er sable depth Character of soil t SEPTIC TANK Bl--Type/MfgCapacity-1 No. S Compartments, �1 PKG. TREATMENT PLT. ❑ Method of Disposal ." xaDistance to nearest: Well Foundation Property Line LEACHING LINE f No.. & Lengtfl-of'lines �r Total length/size FILTER,BED, r �. ElDistance-tonearest: • Well Foundation==tL.Q Property Line k - Number �r SEEPAGE PITS CYLDepth�""-_��"'-'Size - - - N SUMPS ❑ Distance to nearest; Well o Foundation' -)" O Property Line _ DISPOSAL PONDS ❑ r �_ J., 1 F ".I hereby certify that I have prepared this application andThat 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. �- ^, 1 Home owner or licensed agent's signature certifies the folfowing: '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- ition-laws of California." •,j .;- .f The applica st call for a requ'ed i ctions p1 to drawing on r terse side. 1 9 ). _. Date: r d r f Signe Title: ' FOR DEPARTMENT USE ONLY A Application Accepted by sDaie, Area a f drGrout Inspeatiorrti� ate ('Inspection fay Date A ditional Comments: k 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 k Applicant Return all copies to: EnvironmerrtaCHealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. INFO i + EH 13-24(REV.1/a 5) S` �� T '• EH 14-26