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APPLICATION FOR,PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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. I Job Address �4City rte. Lot Size PM Owner's Name _ Address- :r"077x�3_._ hone S� /Q` -i5J Contractor � .�.. Address � �D icense No. Phone TYPE OF WELL/PUMP: NEW WELI WELL REPLACEM NT DESTRUCTION ❑ .PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SD�t SEWER LINES DISPOSAL FLD. :52 2" PROP. LINE (\ { FOUNDATION AGRICULTURE WELL OTHER WELL S�r!" PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X Domestic/Private X Gravel Pack 111 Tracy Type of Casing AV(i Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal SD Type of out ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms , Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg 1 ° Capacity No. Compartments PKG. TREATMENT PLT. ❑ l Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size _ Number f SUMPS ❑ Distance to nearest. Well .-- - Foundation Property Line DISPOSAL PONDS ❑ — - 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. 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 California." The applicant m just call for all requi d inspections. Complete drawing on �v`errssef side. q Signed Title: /�t�(� -d� Date: 7-2 X6 FORD RTMENT USE ONLY r 4pplicati ccepted by Date -7-1 y Area t7 —7 e Pit Grou spection by -te Final Inspection by Pate Additional Comments: , ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83543M Applicant- Return all ier)f to:.Enyif onme tal J!�thit/Servic1601 E. _ Hazelto_n Ave, P.O. Box 2009, Stk., CA 95201 mi, FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT''NO, INFO ��+�/� + EH 13-241REV.1/e 57 '( GdJ't• oo ��Q�Q�� U v' 77FIy/ f EH 14-29 r. f