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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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 �`'� ,Y `�S�//7,/Cf ff•1 -� city �+C Lot Size PM �.�/� u-S /'r. Address Phone Owner's Name � L'irsuGfa, t : 1�fien/nG� PD.� /1/u✓ 47D sc �sAPo� 7� -5�a 3 '72 CeRUaetor o/1 Address ense No. v�(o8� Phone TYPE OF WELL/PUMP: NEW WELL-51- WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER'fr mon r DISTANCE TO NEAREST: SEPTIC TANK SEWER.LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C•CJt I�s�r lit fi j /.Z Dia. of Well Casing Ind? [n ❑ Open Bottom ElManteca Dia. of Well Excavation Gravel Pack ❑ Tracy Type of Casing uii P✓L Specifications ❑ Domestic/Private yZ C ❑ Other Cl Delta Depth of Grout Seal ��,p Type of Grout ❑ Public � ❑ Irrigation �APprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Ddrie�' `- Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Noi sepeic sy em rmitted'rf public sewer is Installation will serve: Residence— Commercial_ Other Number of living units:— Number of bedrooms Water table depth Character of soil to a depth of 3 feet: � SEPTIC TANK ❑ Type/Mfg No No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well FlOundation Property line SEEPAGE PITS `❑ Depth -Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 applicant mut all for all regwr d i spections. Co to drawing on reverse side. � �� Signed ' Title:�•�,LG C-z/sT Date:_ O - FOR DEPARTMENT USE ONLY ... �,- Date -�? Area Application Accepts y /2 Pit or Grout Inspectio y r Date Final Inspection by +G s Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to:knvironmental Health Permit/ ervices 14101 E.liazelton Aye., P.O. Box__ N2009, LStk., CA 95201 1, JA—CJ-Q FEE MOUNT DUE AMOUNT RE ITTED CKJ RECEIVED !1 DATE PERMIT NO. c - j EH 13241REV.1/e51 5 0 t/r0 C / �`LL i EH 1426