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APPLICATIMFOR 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) L 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.- _ lw Job Address a4l City rte Lot Size`ya PM— I �" [' Owner's Name eI a `�I!'5AS Address/ ZQSJO LdLl1r5e Phone010 Contractor's NamM' 10�&410 License No., �4� / Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 11 PUMP INSTALLA,TIIO,N� - SYSTEM NK REPAIR El OTHER El �},� DISTANCE TO NEAREST: SEPTIC TAJ SEWER LINES It'�C�"—�k DISPOSAL FLD. r PROP. LINEf.2 P FOUNDATION AGRICULTURE WELL A)aLY,OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J) S ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Z, Dia. of Well Casing 1 [ Domestic/Private Gravel Pack ❑ Tracy Type of Casing r ok Specifications ❑ Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grou A-MAI ❑ Irrigation --Approx. DepthEastern Surface Seal Installed by J �i Repair Work Done 4r Type of Pump H.P. c-]( .I 6M State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1 ¢ available within 200 feet.) j Installation will serve: Residence �. Commercial Other Number of living units: Number of bedrooms # Character of soil to a depth of 3 feet:i _ '-' " t � Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments l PKG. TREATMENT PLT. ❑ l� Method of Disposal " s '� Distance to nearest: Well; Foundation Property Line1 ty f LEACHING LINE ❑ No. & Length of lines I 4 Total length/size i FILTER BED ❑ .Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth I Aizef ` Number SUMPS ❑ Distance to nearest:.o Welil �Founda'tion Property Line DISPOSAL PONDS LII / 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. w Home owner or licensed agent's signature certifies the following: "I certify thet 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 applica call for all required inspections. Cf omplet drawin_g'on reverse side. / f Signed Title$ Z 1 _ Date: FOR DEPAR ENT USE ONLY Application Accepted by ' Date yT Area Pit or Grout Inspection by 7 M i Dater Final inspection byf Date ' 6ytju r Zl,r, dEl,�Y-� fil [JvI Cry"" �1 Crw.�7fiu.. 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 E - -- U.... CK- _ .,.._..-..k �----- — -'_�___,.. i7.- INFO AMOUNT DUE.t AMUUN REMITTED RECEIVED BY�"� DATE PERMIT•`NO. • +EH 1324 IREV.101831 ° t3 3 H yUfO n[i} -8s -i 38s Eli 14-26