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APPLICATION FOR PERMIT + SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE., STOCKTON, CA { Telephone (209) 466-6781 1PERMIT 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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. s fi 1 /0 CJ Job Address p ��' City Lot Size PM Owner's Name f�fJ n�' '+194U Address ! ' 7 Phone r Contractor Address © C.�.��[ License No. S�'d S�S _Phon Q• 3'". i TYPE OF WE NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑1. 4 i� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ {� i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE 1 FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC'rION SPECIFICATIONS II ❑ Industrial 171Open Bottom LJManteca Dia. of Well Excavation Dia. f Wions sing d Domestic/Private 13 Gravel Pack ❑ Tracy Type of Casing Specifications i ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout �> ❑ Irrigation ---Approx. Depth 11Eastern Surface Sea4 Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done° a '' Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is ' vailable within 200 feet.} / Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms k Character of soil to a depth of 3 feet:i ' Water table depth SEPTIC TANK ❑ Type/Mfgr Capacity ham,_-"- - No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal r Distance nearest: Well Foundation Property Liner LEACHING LINE ❑ No. & Length of lines Total length/size r" FILTER BED ElDistance{c nearest: Well Foundation Property Line qr+; ,1 •� I SEEPAGE PITS ❑ Depth Size Number i SUMPS ❑ Distanceto nearest: Well Foundation Property Line 1 DISPOSAL PONDS ❑ I I I 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 lawns, and rules and regulations of the San Joaquin Local Health District. 4 1 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 Califor Thelicant ca r all ired inspections. Complete drawing on reverse side. �• i Signed Title: tl�La �'^-��- bate: '_/ FOR DE RTMENT USE ONLY Application Accepted by VV Date ;�^ Area I I�. Pit or Grout Inspection by ' Date Final Inspection b Date Add' onal Comments: Add 466-6781 ❑ 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 EEE AMOUNT DUE" AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. CASW INFO +EH13-241REV.7/65) ��" �, miry 9 EH 14-28 -