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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED (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. .fob Addressvs r- •� �� _ City Lot Size PM Owner's Name 4; 4AZ.0 i(AiV4F7^f Address 47/31 C4 fifArrIF 2>4 Phone 9J2_910;V_ Contractor, �5� f[A"_Z;1 Address.7 Y• �� License No.W14'Y7G Phone -3 9 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ %I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 11LI DISTANCE TO NEAREST: SEPTIC TANK SEWER NES DI L FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Y= INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS ❑ Industrial © Open Bottom ❑ Mantec Dia. of Well Excav"ation Dia. of Well Casing Fill ❑ Domestic/Private ❑ Gravel Pack cy Type of Casing Specifications" Cl Public C-] Other ❑ Delta Depth of Grout Seal Type of Grout I IIrrigation A �. ppr . Depth l l Eastern Surface Seat Installed.by Repair Work Done O Type of ump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50'1 TYPE_OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITIONAi DESTRUCTION l 1 (No septic system permitted if public sewer is ' available within 200.feet.) 1-11 Installation will serve: Residence Commercial_ Other Number of living units: _,L- Number of bedrooms 7 Character of soil to a depth of 3 feet: Al:J> _ Water table depth r SEPTIC TANK ❑ Type/Mfg LR �.ti f� 'Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: y Well Foundation Propl=rt,f.Line LEACHING LINE C+�No. & Length of lines 4,0 Total length/size 4� , FILTER BED ❑ Distance to nearest: Well SQ r Foundation 20 Property Line _ SEEPAGE PITS I'] Depth 11 Size 7- x t a Number 1 SUMPS A. /Distance to nearest: Wel! 400 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 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspec'ons. Complete drawing on reverse side. Signed X Title: (fn� + Date O FOR DEPARTMENT USE ONLY Application Accepted by Date Ala— Area ,a Pit or Grout Inspection by Date Final inspection by Date g� Additional Comments: / Awv ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy 835-6385 PIL Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIVNO. EH 13-24[R EH 1 4-20 EV.I/K5) r® �- - Y }Bl11