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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 i? PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {� (Complete in Triplicate) it 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local health District. ?+ Joh Address City /Wyr�A• 'Lot Size /x 6YC PM i �Yic 1s GCL,C` Address /�� -rel,/e m� _ Phone Owner's Name , Contractor's Name / A!Yr/.�/J! je /y License No. �`��i9 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ k PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ w —. OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE: FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE, TYPE OF WELL PROBLEM AREAS CONSTRUCTION SPECIFICATIONS ❑ Industrial = ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private 171 Gravel Pack El Tracy , Type of Casing_ Specifications ❑ Public I. ❑ Other ElDelta Depth of Grout Seal Type of Grout ❑ Irrigation r --L-Approx. Depth ❑ Eastern Surface Seal Installed by State Work Done I! Repair Work Done i ❑ Type of Pump H.P. Well i ❑ Well Diameter Sealing Material (top 50'1 I Depth Filler Material (Below 501 �! f TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR ADDITION EDDESTRUCTION El (No septic system permitted if;public sewer is available within 200 feet.) 11 : Installation will serve: Residence X Commercial_ Other—" — Number of living units: Number`of bedrooms ' it Character of soil to a depth of 3-feet?" Water table depth SEPTIC TANK I$ Type/Mfg: Ae 5, Capacity t oo No. Compartments x PKG. TREATMENT PLT. ❑ r 70/�1_ Method of Disposal Distance to nearest: Well �"' T Foundation_ /s Property Line LEACHING LINE S�No. &Length of lines ; 3 — x-70 Total length/size A J V � ` r FILTER-BED El Distance to nearest: Well d undation A-1- Property Line 5' ' SEEPAGE PITS r ❑ Depth Size Number ` SUMPS ❑ Distance to nearest: Well foundation 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 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 must call for all required inspections. Complete drawing on reverse side. Signed1w y I Title: -? Date: �•" /~fix # I P FOR DEPARTMENT USE ONLY d Application Accepted by I r Date 2 � Area { Pit or Grout Inspection Date Final Inspection by Date��'�� ! li Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El 835-6385 '! Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 - FEE DATE . PERMIT':No." INFO AMOUNT DUE ,F AMOUNT REMITTED CASH RECEIVED BY �;,, - - - •- + EH 13-24 MM 10r83) EH W26 r �