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f 00 APPLICATION FOR PERMIT 'SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 EZHAZEL T ON AVE., STOCKTON, CA - Telephone (209? 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) -Application is hereby made to the San Joaquin Local Health District for a pb' it t6,&onstFct 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. Y ,< `� yJ Job Address O /1J�/� � /C - city Lot Size PM , Owner's Name 1 �'v �� 5 Address /��y �� Phone r Contractor /u Address kJ6')r❑cense No.-�*re%6 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 151 DESTRUCTION ❑ PUMP INSTALLATION,53, SYSTEM REPAIRt 6 OTHER ❑ DISTANCE TO�,NEARES.T.:_SEP_TIC TANKn. _SEWER-LINES — DISPOSAL FLD. PROP. LINE r i FOUNDATION - AGRICULTURE WELL-- - "OTHER WELL 'PITSISUMPS INTENDED D SE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑-Open-Bettonr-� Manteea---•—••-Dia:-•of-WeW-Excavation~- --Dia. of Well Casing )6Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 1 Type of Grout ❑ Irrigation =_Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Dane ❑ Type of Pump '�? � H.P. State Work Donett a . Well Destruction ❑ Well Diameter Sealing Material Itop 501 I rl 1 f !I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION'❑ DESTRUCTION INo septic system perrilitted'if public sewer is UP available within 200 feet.) '� I Installation will serve: Residence_ Commercial— Other !Number of living units: Number of bedrooms +'��I � � Y '. Character of oil to a depth of 3 feet:. i • Water itable depth SEPTIC TANK ❑ Type/Mfg s �« - r ty Capaci °} �� � Na. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest':" —Weil ' aundation _ fsroperty Line r LEACHING LINII ❑ iNo. & Length of lines F otal I ingth/size F�LTER BED El Distance to nearest: Well ` Foundation, Property Line SEEPAGE PITS ❑ Depth Size f.r:� Nuber i k! i ) r - r ,SUMPS E] D!stance to nearest: Well Foundation` I. i 'Property Line DISPOSAL PONDS F-14 T"�""'— j` l 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 Seh Joaquin Local_Health-Districf:� _ - r� I Home owner or Jicensed agent'6,signature certifies the following: t certify that in the pert m�incJ of the work fwhich this permit is issued, I shall not '+ employ any person in such mariner as to become 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 pArsons subject to workman's compensa- tion laws of California." i The applicant' II requ' d inspections. Complete drawing on reverse si e. \ i r �Signed X ,, ,._,...__ - Title: � Date: z OR-DEPARTMENT USE ONLY Application Accepted by_ �- Data Area Pit r Grout I coon by ate?-1Final Inspection by � D'a'te Additiona om'?�ents£' ❑ Stk '466-67811 _r ❑ Lodi 369-3621, ❑ Manteca 823-7104 ❑ Tracy 83x6385 Applicant- Return all copies to: Envi;roonmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2006ttkINCA 520117 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED dY /DATE PERMIT NO. + EHM24MEV.1/e57 EH 14-26 1x'75 d0