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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL TON AVE., STOCKTON, CA 'Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t . . 3 .. (Complete in.Triplicate) c 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. D _Y" �Qwl +�lu�' L�'I `S ocI 4 '# Joh Address - City Lot Size PM w,. .. _4 "I l� -- Address -- - o r� Owner's Name �[�°�� r s,4-N-•G 11-5 .�}� Phone ContractoEp Q- �A� s4 foo s Address XF 9:6 - �i L4.1.E License.No.2-Sy3 y3 Phone 'W/�-96-b7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ w PUMP INSTALLATION ❑ STEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LIfRE DISP05AL FLD. PROP. LINE FOUNDATION AGRICULTW OTHER WELL PITS/SUMPS f! INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRUCTION SPECIFICATIONS f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation �4pprox. Depth ❑ Eastern Surface'Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter, Sealing Material (top 50') Depth Filler Material (Below 50') �} TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑. (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence—K-- Commercial., Other ? 't Number of living units: Number of bedrooms i f Yy Character of soil to a depth of 3 feet: -_ 1,S T Water table depth " SEPTIC TANK ❑ Type/Mfg CapacityA -x No. Compartments ` 1 ' PKG. TREATMENT PLT. ❑ � �� `�� /� � Method of Disposal r Distance to nearest: Well L 'Found`ation ZS Property Line ZS LEACHING LINE No. & Length of lines TTotal length/size FILTER BED ❑ Distance to nearest: Well �M Foundation Property Line P SEEPAGE PITS f�''Depth '7-5 7�5 - w Size �– Number SE SUMPS ❑ Distance to nearest: Well0_� p 1 Foundation s f "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 certifie's the following: "t 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." ' Theapplicant m st call for all required inspections. Complete_ _drawing on reverse side. ' Signed X —Title:itle: Date: f FOR DEPARTMENT USE ONLY Application Accepted by _ Date Area jD 23 Pit or Grout Inspection by �Date ,,�ate ns coon by Date - 7 Additional Comments: y ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies 4o: E ironman I Health Permit/Services. 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 DO Yt0 �OB� rr ��G FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. ''+ EH 13-24(REV.vin 5) J ' ' EH 14-28 - I do -9-7 67-3k-7(1