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F I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT E 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete i -+n 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 Regulation of the San Joaquin Local Health District. Job Address �J •�. 1LF�Y lei. City Lot Size ��' rP1rt Owner's Name t'" � `Address'.�3Q +l -O -CL& Phone - at f 14 4. c'i j,C_ r� 4� Ltr 10-1(V Phone f Contracto ----^ a x? Address . License Noy c3�o�"5 CJS TYPE OF WELL/ PUMP: NEW WELL ❑-WEL17REPMCEMENT-0- DESTRUCTION'❑ -' - ' "-r r CASH PUMP INSTALLATION ❑ ! SYSTEM REPAIR ❑ OTHER ❑ PERMIT''NO. • DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS !` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing l O Donliestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing. Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout So�1 Type of Grout - ❑ Irrigation _Approx. Depth s ❑ Eastern Surface Seal Installed by Repair Work Done D Type of Pump ' H.P. State Work Done Well Destruction O Well Diameter Sealing Material (top 50') t Depth i Filler Mat�fral Ieelow 50') 1 TV DC r1C CCDTI/` %A) -W. KILYwI IAICTw, I w-1, �.-w ..w,.e...... f-. __.._.. _ .... Installation will serve: Residence V, Commercial Number of living units: _L_ Number odroo� Character of soil to a depth of 3 feet: SEPTIC TANK t7 Type/Mfg f PKG. TREATMENT PLT. ❑ ' D Distance to nearest: D system permitted if public sewer is within 200 feet) tar table denth / SO + r r 1'ethod of Di pogalh� N all ate© Foundation property Line,,. f'%<"'r i" LU LEACHING LINE U?"*' No. & Length of lines 3— �0 + Total lengthlsizee� c�U Xo 1 tl FILTER'BED IDDistance to nearest: Well (CrG Foundation I a r 3 Property Line �v _ SEEPAGE PITS Depth Q S I r UMPS ❑ Distance to nearest: DISPOSAL PONDS ❑ Sizeyvl. Dumber Well zs-dFoundation /!3 �--Ptbpeity-LrrTe -•I I 1 jereby 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 and7egulations-of-the-San-Joaqui6-Local-Health-District . . -tE*A F�ome owner or licensed agent's signatuie certifies the following: "I certify that in the performance of the work for which this permit is issued, I sliall not i employ a nyperson-in-such-manner as -to -become -subject to-workman's-compensetion -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, 1 shall employ persons subject to workman's compensa-tion-laws of California." \ I The applicant mt call fo all required inspections. Complete drawing on reverse side. ti y I Signed Title-' ' ' Date: / '"-� FOR DEPARTMENT USE ONLY _ i v 0/Application Accepted by`"��'/ Date " Area r ^1 Pit r Grout Inspection by Date Final, Inspection by Date <q -Additional Comments: ❑ Stk ; 4Efr6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 13-24 (REV. I/es EH 14-28 N FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT''NO. •