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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. m(� � Job Address _dS;KFJ /b of- 4 Jy ,0f.'+� M&69E iCity Lot Size PM Owner's Name V.4h) 11 6. Address 42343,% Phone O Contractor_ ----- Address License NoanR D _Phone 81%� FJ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i ` PUMP INSTALLATION 'W' SYSTEM REPAIR ❑ OTHER Cl DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. .PROP. LINE FOUNDATIONAGRICULTURE WE�� `=BOTHER WELI_7NN .PfTS/SUMPS INT NI]ED USE -r7YPE OF WELl;. PROBLEM AREA' CONSTRUCTION SPECIFICATIONS t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing P-60mestic/Private-- O,Gravel Pack" �"'�"'"'"�0-Tracy Type-of-Casing -- _Specifications i'l Public n Other ❑ Delta Depth of Grout Seal Type of Grout _ I R Irrigation _.Approxi Depth I I Easternri Surface Seal Installed by Repair Work Done &0- Type of Pump S.Z..5 H.P. /_�S m State Work pane A+S7'/JF I-L..Ss U Well Destruction ❑ Well Diameterr Sealing Material [top 50') j Depth f Filler Material {Below 50') j TYPE OF SEPTIC WORK: NEW INSTALLATION f'l REPAIR/ADDITION f l DESTRUCTION l I (No septic system permitted if'public sewer is r available within 200 feet.)' Installation will serve: Residence t� Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:'1 Water'tabfe depth t ' SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments �^{ PKG. TREATMENT PLT. ❑ �. i Method of Disposal v �a Distance to nearest:. Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines € Total length/size t FILTER BED ❑ Distance to nearest: Well Foundations Property. Line, �£} SEEPAGE PITS y I I Depth Size Numberr, �^�� C - - SUMPS :� �Q �❑ Distance to nearest: Well _Foundation, _Property Line+ t41 DISPOSAL PONDS f ❑ 1 j vt„ j v177 I hereby certify that I have prepared this'application and that the work will be done in accordance vi iifiksan Joaquirt,eoun'ty oYdinancesj state laws, and rules and regulations of the San Joaquin Local Health District. I 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 applican t call for all requ' inspe 'ons. Complete drawing on reverse side. Signed X Title# Date: FOR DEPARTMENT USE ONLY !�/j / Q Application Accepted ba Date f`� ea Pit or Grout Inspection by Date Final Inspection by Dat Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 II i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVER 8Y RATE PERMIT'Np. INFO CASH + EH 13-24(HEV.F/H5) / r6/[M/ 1—J 11 _CJ'"G ( EH t4-2B 1 _l 1 1 qhs - F