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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 } PERMIT EXPIRES i YEAR FROM .DATE ISSUED_... ,i (Complete in Triplicate) , : I? 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 City 7�'NLot.Size .5'i�1!/tFL' PM Owner's Name -A6,4 K &LL, Address ; Cog 0 Phone Contractor's Name C Z&gn 02 License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT` DESTRUCTION ❑ PUMP INSTALLATl01�. SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /.S`6 ` SEWER LINES DISFIOSAL FLD ._ PROP. LINE ie ` =� FOUNDATION AGRICULTURE WELL OTHER WELLa PITS/SUMPS INTENDED USE-\'-"STYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing PC Domestic/Private G 40 Cit ravel Pack ❑ Tracy Type of Casing ddL Specifications /!'O ❑ Public ❑ Other * ❑ Delta Depth of Grout SeaE ,$'la` Type jpmuit a ❑ Irrigation Approxt Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump -51,6 H.P67 . State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth .I 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 Commercial Other Number of living,gnits� Number of.bedrooms Character of'-soil to a'depth of 3 feet: Water table depth SEPTIC TANK x"� ❑ Type/Mfg ° Capacity No. Compartments. PKG. TREATMENT,PLT. ❑ Method of Disposal TREATMENT, Distance to nearest: Well. Foundation ! = Property Line �yi � F tP � I r� l ,f► LEACHING LINE ❑ No. & Length of lines otal length/size i FILTER BED 1' ❑ Distance l nearest: Well ?= Foundation `" Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest:w6ll - Foundation`---" Property Line DISPOSAL PONDS ❑ j 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 i employ any person in such manner as to became subject to workman's compensation laws of California." Contractors 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 II for all requireins ctions. Complete drawing on reverse side. Zroz/Signed Title: Date: FOR DEPARTMENT USE ONLY / Application Accepted by Date Area d Pit or Grout Inspection by Da Einal In tion by Data Q LT .S i A ditiona! Comments: ApStk 466-6781 ❑ Lodi 369-3621 ❑ anteca $2371 ID Tracy 835-6385 p icant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO.' INFO CASH ty ft + EH 13-24iREV.10183} Q EH 1428 O �`^"I e!'S �L �'��—O� �'�-2.71.