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VP APPLICATION FOR PERMIT ) f SAN JOAQUIN LOCAL. HEALTH DISTRICT `J 1601 E. HAZE T ON AVE., STOCKTON, CA .42 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 oe, 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,1 Job Address !. C( City Lot ,Size PM ^� Owner's Name &44 e? C Address 5 15 /dUQ�Ci�/ Phone ` i �Contractar Address /da, � ,�_.�$A License No. Phone TYPE OF WELL/PUMP: NEW WELL_EJ _--" ,WELL REPLACEMENT ❑ DESTRUCTION ❑ `"--PUMP-INSTALLATION C1 --��.-.•-SYSTEM'REPAIR-❑'"""""""'""""""----•OTHER€ -❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE # FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS \ , INTENDED USE TYPE OF WELLPRQBLEM AREA r CONSTRUCTION rSPEG�(FICATIONS ❑ Industrial ❑ Oen Bottom a - � 1 -�'� p � El Ria. of Well Excav,ationjt .Dia; of Well Casing ❑ Domestic/Private " ❑ Gravel PackTracy Type of Casing c i ' j A Specifications F1 Public i "1 (1 Other flLr:tern------__Sujface.1Sea ta De th o Grout!Se I ' 1 Type of Grout �� tl p # I I Ifti ation -- _ A rox. Depth 4� t g �� _ qp Pl In$ta ed by Repair Work.Donee❑ T p p Type of Pum H. -.` State Work Done Well Destruction ❑; Well Diameter _ Sealin 'aterial (top 50'1 i I r ! , r y } I �,.._..t.-1 Depth •. __ ,;. .Filler MateriallSelow 50'I •• TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is !� i `mow` vailable within 200 feet-) Installation will serve:{ Residence_ Commercial_ Other 9 V Number of living unit`s: Number of bedrooms Character of soil to a depth of 3 feet: , SEPTIC TANK 1 Water table depth F �. ❑ Type/Nlf9 Capacity 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 �'i±I--Distarvice-fo-nearest:, Welk. - -Foundation --_Property-Une---- SEEPAGE PITS l I Depth Size Number SUMPS D 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 Di1trict. 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 th performance of the work for which this permit is issued,t shall employ persons subject to workman's compensa- tion laws of California." The applicant c II for all requir in pections. Complete drawing on reverse side. X Signed X L. Title: SJrr��to ar_ �%�, fy/ Date: r ,. h._ FOR DEPARTMENT USE ONLY Application Accepted by Date 2 Area I _ Pit or Grout Inspection by 4 Date Final Inspection by-� (�� Date S �S Additional Comments: �"2`M ❑ Stk 466-6781 b 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, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY / DATE PERMIT•NO- + EH:4.24tREU.tiK51 '61"?J_ C6 EH 1428 - V "T / [J