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APPLICATION FOR PERMIT *N JOAQUIN LOCAL HEALTH DISTF 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2091 466-6791 PERMIT EXPIRES 1 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. Job Address/rjYj:3 >*'- �� /'(/- CityLot Size PM r Owner's Name JJ �� 1fV.'�,.!ti Jam) i�� Address /(�La Qy >��U.� =�� Phone4-�p`f—9`/R'30.'a li/'i U!2lT�GNEYN l C�G_ Go. f�W vJr t-1'J �dF,I�J.i to ContractorGl2^/'iT Addressct7 sx !f_ , License No. Hei7C1' Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X '�j!71.e.1 1U6 H� DISTANCE TO NEAREST: SEPTIC TANK > I Ob SEWER LINES > f 02 DISPOSAL FLD. 2ICO PROP. LINE �t( FOUNDATION �> th0 AGRICULTURE WELLS_[ OTHER WELD PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Erzavatton nif Dia. of Well Casing C1 Domestic/ Domestic/Private ❑ Gravel Pack Cl Tracy Type of asrng Specifications M Public '�4 Other-765-f HOLE F Delta Depth of Grout Seal Type of Grout I I Irrigation —L Approx. Depth I I Eastern Surface Seal Installed by T ump K.TE'1C.. Repair Work Done ❑ �Fype pe of of�ump H.P. State Work Done _ a Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 t\r. TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Dispossalle Distance to nearest: Well Foundation Property Line P_AY eY°E RECE'ED LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Pro party Line' 1191, SEEPAGE PITS I I Depth Size Number I rP�i IBL( Ht A`.1 SUMPS Ll Distance to nearest: Well Foundation Pro ,J, r e DISPOSAL PONDS ❑ 1 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." The applica must call It 11 required inspections. Complete drawing on reverse side. SignedX ��"' '�'—� Title: L/� OL-Ori/ Date: �Z / FOR DEPARTMENT USE ONLY Application Accepted by // lA- Date Area �}q Pi[ or Grout Inspection by !EZ Date T 7L Final Inspection by Date 7-d G3 Additional Comments: ❑ 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. Box 2009, St INFO AMOUNT DUE AMOUNT REEmnrTED CASH RECEIVE BY DATE /} /PjERMIT'NO. . EH 14-M(REV.rrner x'ry �O ��7Z 71-- /0 D EH a-ze U / 0 /