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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ' PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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 lo��77 11,E ! 1 City Lot Size PM�7 Owwnne�,r�ss Name Wig.IL. C` Lave C�IJY_Ah Address � Phone cad r2 I//!�l'�7r/� �C.lin�s c�C.l j�f dress -Y 1SLI��IL Contractor 13&0-&5� License No. Phone O Y e�C.t�YX TYPE OF WELL/PUMP: NEW WELL tT WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION .[!9J SYSTEM RFPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES W.-.;6_,_ DISPOSAL FLD.. # PROP. LINE 414-6 FOUNDATION AGRICULTURE WELL A�M_ )THER WELL—_?lL_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing A-tFomestic/Private ["ravel Pack ❑ Tracy Type of Casing r Specifications F"] Public C] Other ❑ Delta Depth of Grout Seal Type of Grout Q) _ I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done {cam Type of Pump QL J H.P.__ t State Work Dane_ el! Destruction ❑ We�Diametg,�Se ling Material (top 50'I r Material f8elow 50') TYPE OF SEPTIC WORK: N /ADDITION I I DESTRUCTION I i (No septic system permitted if public hewer is available within 200 feet.) installation wills esidenca_____ Commercial_ Other Number of living units: r of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest: Well Foundatio Property.Line LEACHING LINE ❑ No. & Lerigth of lines Total lengt - e FILTER BED LJ Distance to nearest: Well Foundation Property Lin SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ rules and regulations of the San Joaquin Local Health District. 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- 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 Califoro The applicanttfn call for ail required inspect' nsh CompI to drawi'g on reverse side. Signed _ Date: f 1 # FOR DEPARTMENT USE ONLY r Application Accepted byDate Area Pit or Grout inspection by D. Final Inspeskpn by Date'-?—�-� I J Additional Comments: ❑ Stk 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 FEE AMOUNT DUE AMOUNT REMITTED <� RECEIVED BY DATE 6PERMI7'NO. INFO +.EH 13241REV.1inst 1 0 S fj—J o� a�� F// �] (� � EH 14.28 r / b�` i/'