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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' . 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 N okii du.w4A . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l � _ j (Complete in Triplicate) Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described, This application is I made in compliance with San Joaquin County Ordinance No. 549 for sewage or No.-1862 fors ell/pump and the Rules and Regulations of the San Joaquin Local Health District. City Lot Size A0 2300 PM Job Address -�S Address / � Phone Jc`� 3 5-1I wner's Name ,� f�(r-' Gt S2fGFw (5 3 h f� Phone Contractor Address License No. T PE OF WELL/PUMP: f NEW WELL ❑ WELL REPLACEME ❑ DESTRUCTION ❑ PUMP INSTAL N ❑ SYSTEM RE 1R ❑ OTHER ❑ iSEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC(TANK AGRICULTURE WE OTHER WELL PITS/SUMPS FOUNDATION l INTENDED USE TYPE OF WELL PROBLEM EA CO TRUCTION SPECIFICATIONS Dia of Well Casing El Industrial EJ Open Bottom ❑ Manteca D' . of Well Excavation Specifications El Domestic/ of Casing Domestic/Private ❑ Gravel Pack LITracy Dep of Grout Seal Type of Grout i t ti C"1 Public ❑ Other' Fl Delta j Approx. Depth I 1 Eastern Surface ,I Installed by •:1 l Irrigation — State Work Dane f Repair Work Done ❑ Type of Pump Sealing Material (top 501 Well Destruction EDWell Diameter Filler Materia! {Below 50') Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I 1 DESTRUCTIO afvailablelwithin 200 feet.) if public sewer is Installation will serve: Residence Commercial Other Number of living units: t Number o bedrooms i - - Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg Gapacity ( Method of Dispo�l 4 PKG. TREATMENT PLT. ElDistance to nearest: Well Foundation — Property Line 1?J r t Total length/size LEACHING LINE ❑ No. & Length of lines Property Line FILTER BED CI Dist ance to nearest: Well Foundation l i'I Depth Size Number SEEPAGE PITS Property Line SUMPS D Distance to nearest: Well Foundation Pe rtY DISPOSAL PONDS ❑ I 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. 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 Home Homeany person in such manner as to became subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature employ 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 t call for all req e s ns. complete drawing op verse std x Signed X Title: 1 Date: ?� f \ �MEDLI_USE ONLY Date Area Application Accepted by00 v Date Final Inspection by Pit or Grout Inspection by �` 1 6e. kIt,.P� 3 ( Qf. rc.n �vs,ur�^;2�-�C�'t .1.K-t.w+�,l 4.1-d4.1-do` -� Additional Comments "1 � 1"4` ❑ Stk .466-6781 E) Lodi 1369-3621 El Manteca 823-7104 ❑ Tracy 835-63135 ` Applicant- Return all copies to: nvironmentel Health Permit/Services 1601 E. Hazelton Avg-P.O. Box 2009, Stk., CA 95201 1..- w.'1'1. d�r�b b.-DH-e"" .f �.--'�-�.(�/�=J1� , [ d ' . Atd FEE CK RECEIVED BY BATE PERMIT NO. INFO MOUNT DUE AMOUNT(jR�)EMITTED CASH +..EH 13.24(REV,J/KbllV�� EH 14-28 w;