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I; APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 k !I PERMIT EXPIRES 1 YEAR FROM'DATE..ISSU,ED Y t• V .4 (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. Job(Address f (r lriV er City' �7 f Lot"Size 1 PM~ Own'er's Name ( !�-v/, 't__ /Address Phone I � Contractor Address License No.4WSIP40 Vcf' Phon Vila> TYPE OF WELL/PUMP: (NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ If: PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ w A DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE S ;. FOUNDATION f i "� �IAGRICULTURE WELL OTHER WEL=L PITS/SUMPS " INTENDED USE TYPE OF.WELL PROBLEAAEA CONSTRUCTIpN°SPE IC FICATIONS �' I ❑ Industrial ❑ Open Bottom LJMantecai- Dia. of Well ExcavatioN - Dia- of Well Casing �. I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy q'" Type of Casing Specifications ❑ Public ❑ Other € ❑ Delta De-pth`of Grout Seal Type of Grout ' ❑ Irrigation _—Approx. Depth ❑ Eastern Surface Seal-Installed-by-_� -- Repair Work Dane ❑ Type of Pump H.P. State Work Done `JI WellyDestruction ❑ Well Diameter Sealing Material (top 501 I Depth , Nller-Material-(Below 50'I of T �"r�ft-�.� i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system`permitted if public sewer is Yavailable within 200 feet.) Installation will serve: Residence - Comi ercial Otfie,ioll 4 A , ! Number of living units �Nuniber of'b_edrooms3✓r� " Character of soil to a depth of 3 feet _. f Water table depth `` r SEPTIC TANK ,❑ Type/Mfg Capacity No- Compartments I, PKG. TREATMENT PLT�C " , Method of Dipposal I Distant d to nearest:" Well Foundation Property Line I LEACHING LINE 0. & L$ngth of lines Total length/size FILTER BED ❑ Distance to nearest:•—Well= - -----=- foundation---------- -----P ro party-Eine----V-'f�"—.--` `" . II t SEEPAG SUMPS E PITS t th ffi D sance to n :--We �earesi: 1Proper[y-Line- mss I DISPOSAL PONDS Cl 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,I shall employ persons subject to workman's compensa- tion laws of California." Y Th pplicant t call forrrmkked inspections. Complete drawing on reverse side. Signed X � Title• Date: 49 FOR DEPARTMENT USE ONLY Application Accepted by Date Area j i Pit or Grout Inspection by Date Final Inspection by Date c- ' Additional Comments: ❑ Stk 466-6791 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,E Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY "DATE PERMIT NO. � + EH 13-24(REY.vR i) EH 14-28 liidi�' i