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APPLICATION FOR PERMIT kV SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA --Telephone (209) 466-6781 PERMIT EXPIRES 1''YEAR FROM DATE ISSUED - (Complete in Triplicate) "``� 1 : ... i.F 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 r made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. fis: M C,>1,57-226-o/ , Job Address v74P44` ' . City Lot Size PM - Owner's Names � /r-//'llblA!i -Address- �/_ Phone Contractor .5'I/C' Address License No. Phone" OF WELL/PUMP: NEW WELL;0 IrT WELL REPLACEMENT ❑ DESTRUCTION ❑ (^- PUMP INSTALLATION ❑ SYSTEM REPAIR.❑ OTHER ❑ ��V}} DISTANCE TO NEARES IC TANK SEWER LINES DISPOSAL FLD. PROP. LINE`W FOUNDA AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL 7PR REA CONSTRUCTION SPECIFICATIONS❑ Industrial ❑ Open Bottom anteca " '' of WeII Excavation # Dia. of Well Casing ❑ Domestic/Private ❑ Gravel'Paci'— "� racy Type of -__ Specificationsy ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout r ❑ Irrigation g ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump 7' H. 'State Work'Done , Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth t=iller Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIO DESTRUCTION D (No septic system permitted if'public sewer is V �� ` available within 200 feet./ } Installation will serve: Residence_: 2 Commercial_ Other 1[ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I ' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity =" No. Compartments, t PKG. TREATMENT PLT, [2ppt 1 Method of Disposal °{' Distance to nearest: Well Foundation' Property Line LEACHING LINE No. & Length of lines Total length/ ize FILTER BED F1 Distance to nearest: Well J� r Foundation J d �...- .µProperty Line�Q ! o t SEEPAGE PITS ❑ Depth —Size :zl�3 � �Number _ r SUMPS ❑ LDistance to nearest: Well Foundation ;� '- __Property Line-{ ' DISPOSAL PONDS ❑ I hereby certify that I have-prepared•this-application and-that-tho work will'be done-in accordance ith San Joaquin county ordinances, state laws, and rules and regulations ofIthe 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."II; p The applicant must call.for all requir inspections. Complete drawing on reverse side. , Signed. Title: _ �_ { bate: �—FOR-D`EPAFIT1MIENT'USE_ONLV— Jrl Application Accepted by ✓!f!! Date_�°Z 70 `^85 Area i Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 5 Applicant- Return.all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2069, Stk., CA 95201 ; a FEE CK INFO AMOUNT DUE. AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0.'. + EH 18-24(aEv..3/H 5) Y6 ?:a A", �y ++'i' EH 1426 i