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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 C Ca4c5- AJ (Complete in Triplicate) 0-7 j— l 3p--Cf 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 Ryles and Regulations of the San Joaquin Locai Health District. /j �_ ,�� Job Addie City of Size (/W�� PM Owner's Nam Address J IJ ,,one — I 2-0 Contractor Address x l 41-2-7 License No,16 Z 3 73 Phone 46—16 ZJ TYPE OF WELL/PUMP: NPWmM ELL WELL REPLACEMENT 1 DESTRUCTION ❑ ri PUMP INSTALLATION ge SYSTEM REPAIR ❑ OTHER/ El DISTANCE TO NEAREST: SEPTIC TANK IDG /f SEWER,LINES p- DISPOSAL FLD.LIZLZ�PROP!LINE 1 FOUNDATION ,.AGRICULTURE WELL OTHER WELL PITS/SUMPS 4" -� �. INTENDED USE TYPE OF WELL PROBLEM-AREA .CONSTRUCTION SPECIFICATIONS ' ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ic ❑ Dom stic/Private i_4"Gravel Pack ❑ Trac Type of Casing �� Specifications ( ' ❑ Other � Depth of Grout Sea] 5-0 T e of ut El Irrigation x Approx. Depth ❑ Eastern rface Seal Installed by Q ' Repair Work Done ❑ Type of Pump D.W T H.P. , State Work Done Well Destruction ❑ Well biameter 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 t available within 200 feet.] Installation will serve: Residence_ Commercial ,�.-n' Other Number of living units: Number 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 Foundation Property Line LEACHING LINEEl ;No. & Length of lines Total length/size FILTER BED '\10 r Distance to nearest: Well Foundation Property Line J• SEEPAGE PITS ❑ Depth Size Number" " " `-4 - SUMPS ❑ Distance to nearest: Well Foundation Property Lirie DISPOSAL PONDS ❑ hereby certify that I have prepared this application and tht1hA rk will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of oaquin local Health District. Home owner or lice d agent's sig tura certifies the followirig: 'I.certify that in the performance of the work for which this permit is issued, I shall not employ any perso 5-n such manner as become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies the folio ing:"I certify that in a rformance of thew 5-k for r this per it is issued,1 shall employ persons subject to workman's compensa- tion laws of Ca fornia.' The applicant ust call )r inspectio C g on.re era e. Signed X c r tie: Date: r -4 FOR DEPARTMENT USE ONLY Application Accepted by Date Area r (� Pit or Grout Inspection Date `� Final Inspection bvVIIX Date u Additional Comment ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 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 RECEIVED BY DATE PERMIT"NO. + EH 13-241REV.)/s 5) ^�yTYS 1��pa EH 14-26 O O` d0 - ! X65 i