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APPLICATION FOR PERMIT �7 s SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA LfCJ�-4 [^� Telephone (209) 466-6781 jr� PERMIT EXPIRES TYEAR FROM DATE ISSUED 1 (Complete in Triplicate) / 1 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 weWpump and the Rules and Regulations of the San Joaquin Local Health District. II , Job Address L 1 �2 IZ V G C1 City S�oCao z�Lot Size PM Owner's Name—Z?,/U7 f�I"A L) Wile address �; �Fn f R V D e' 14-1.1-C' Phone Contractor S'e /19 Address License No. Phone TYPE OF WELL/PUMP: I� NEW WELL ❑ WELL REPLACEMENT ❑ STRUCTION LJr " PUMP INSTALLATION ❑ SYSTEM REP OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE f FOUNDATION AGRIC E WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROR TRUCTION SPECIFICATIONS ; ❑ Industrial - ❑ Open Bottom anteca Dia. of We tion t Dia. of Well Casing ❑ Domestic/Private ❑ Giavel Pack ❑ Tracy Type of Gasing Specifications it f 1 Public ❑ O``ther n Delta Depth of Grout Seal Type of Grout F1 1 Irrigation f .�j FAp X. Depth. 11 Eastern . Surface Seal Installed by ` F .._..:_ �M 1 Repair Work Done ❑ "Type of mp H.P- State Work Done f Well Destruction ❑ We%Diameter Sealing Material (top 50'1 { Depth, Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIWADDITION I I DESTRUCTION l Noiseptic system permitted it public sewer is ailable within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: 0Number of bedrooms Character of soil to a depth nFF Ff 3 feet: Water table depth SEPTIC TANK ❑ fp' /Mfg Capacity No. Compartments PKG. TREATMENT PET. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line " QM _ LEACHING LINE ❑ tV�o. & Length of lines _ Total length%size s FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS f! Depth Size Number SUMPS L7 Distance to nearest: Well Foundation Property Line s DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the wark will be done in accordance wlth'San Joaquin county dZlinan'ces,—state-laws;•and— � rules and regulations of the San Joaquin Local Health Dil3trlct. i Home owner or licensed agents 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 mariner 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." r� The applicant must call for all Yequired.inspections. Complete drawing on reverse side. d�I . Signed X- �>FjZi�/C O�3' A- RU.`PVA- Tide:., i-7-0-D.a/L ,iso rA Date: } FOR DEPARTMENT USE ONLY Application Accepted by ;`"' --- Date Area } Pit or Grout Inspection Date t - Final Inspection by L1 dC Date Additional Comments: J� �/�'�-�''r/ 4-- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 -- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Sik., CA 95201 1 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY 1. DATE PERMIT'NO. INFO + EH 4(REV.1/95)EH 12 ��•� �7�• �.J�I 1 -� �. �. `J'`'"1�Y� "a �! T - ..