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' APPLICATION FOR PERMIT Aa SAN JOAQUIN LOCAL HEALTH DISTRICT Vlv�. 1601 E. HAZE.T ON AVE., STOCKTON, CA JA� �D Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDN��RQ �99j (Complete in Triplicate) P'Fk,�SNrAC �� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein� iz6 141 pplication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulatioiiyof the San Joaquin Local Health District. f �( 7� T^ Job Address ref 1 t�U I .5� s t City:5 Lot Size ?M Owner's Name 1-4If15STU6l hjrs Address ��3I �. ,i[ ftirt.-sr LW S�K��11 Phono 73�IfAD Contractor 6Pt_iTt-l.[.+4 aP (f"Address )Zl-L6 No, _SI920?a Phoneq TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER (< IM69ITo1C.1+JC V_)6j,L DISTANCE TO NEAREST: SEPTIC TANK AtPt SEWER LINES f3-�% DISPOSAL FLD. JPI PROP. LINE 14 FOUNDATION 3O AGRICULTURE WELL A!$_ OTHER WELL 14- PITS/SUMPS _±tA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I P] Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing p c— Specifications M Public )4 Other It(6h1ITD0dC0 1 1 Irrigation --Approx. Depth I 1 Ea@tern Surface Seal Installed by WA-112 V300_FC Repair Work Done ❑ Type of Pump H.P. Stare Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION I 1 DESTRUCTION i I (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 t� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well f=oundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 DiItrict. 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 ap mu call fpr all Te red inspection . Complete drawing on r arse side. A 12 Signed Title: Date: 6 FOR DEPARTME T SE ONLY Application Accepted by /�. Date —R)r I Area Pit or Grout Inspection by Date rte+ q Final Inspection by Date 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. 4�v 4)0 /� �f %p 1/} ♦ EH 13-21(REV.r/x 57 K � / I, EN 1126