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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,,STOCKTON, CA a Telephone {209) 466-6781 PERMIT EXPIRES 1_YEAR FROM DATE,ISSUED . Y {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: ' 04�j) T--;. fir. Job Address �/ City i-i4 T Lot Size PM 1, Owner's Name Z_ /VI�/.7 Si/1'"`Address Phone Contractor k110dress 7` Phone 7` �� (License No.�� U TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION RP .SYSTEM REPAIR,LiOTHER ElDISTANCE TO NEAREST: SEPTIC TANK SEWE LINES DISPOSAL FLD. PROP. LINE FOUNDATION . AGRICULTURE WELL OTHER WELL PITS/SUMPS —iNTENDED'USE TYPE-OF'WEE PROBLEM AREA-"" coffgTfRU TION SPECIFICATIONS ❑ Industrial QD:Ope"n�Bbttorr ��.:❑ Manteca Dia. of Well Excavation. pia. of Well Casing ,*Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications El Public ❑ Other ❑ Delta Depth of_GrZo7geal i tt Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installedby ! i Repair Work Done ❑ Type of Pump ,.IZZA H.P. State Work Done,'P&" Well Destruction 11 Well Diameter Sealing Material Itop 50'I- -_ r Depth' Filler Material IBelow 501 + �' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ �Gommercial_ Other r Number of living units: Number ofbedroEms s Character of soil to a depth of 3 feet: �-_ r -�` Water table depth - SEPTIC TANK LJType/Mfg "�1. " Capacity - No. Compartjt, is PKG. TREATMENT PLT. ❑ i � Method of Disposal Distance to nearest: Well Foundation ,Property Line LEACHING LINE ❑ No. & Length of lines^ Total length/size FILTER BED ❑ Distance to nearest:;--17`Ilell Foundation Property Line SEEPAGE PITS ❑ Depth r� A Size µ Number 4 SUMPS ❑ Distance to nearest:-+ tiNell Foundation ('Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this apptic ion'ar d-that-the-work-Wll-be dome'€t acd6r-dance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin LocallHealth'District. ( C t Home owner or licensed agent's signature certifies the-fallowing:�-"I-certify-that'in"the-peb fbOYtt7 lof the work for which this permit is issued, I shall not j 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 th6perf rmance.of the work for which this permit is issued, I6all employ persons subject to workman's compensa- tion laws of California." The applicant mu t c II for I requir d inspecos. Complete drawing on reverse side. t l "�v Signed X Title: — /'� / 77�2ioe —r� Date: Z FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection bJ Date Additional Comments: a . ❑ Stk 466-6781 Ll Lodi 369-3621 ❑ Manteca 823-7104 . ❑ Tracy 835-6385' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O..Box 2009, Stk.,,CA 95201 FEEi INFO "AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. v I -L + EH14-28fREY.S/t751 3