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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES 1 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.Ag CCJJ Jab Address' /�! '3"f�al/ 1 City s' Lot Size e k-_r PM 1s loh Owner's Name � //rte_, 1n ` 11 �✓e- Address lQ �'I —_ Ay6M &e,. C Phone Contractor r / '1'.g �►2 '. Address 2 / r /i. 4/ "Ile License No. Phone 9i1 ?,2102.2-1 TYPE OF WELL/PUMP: NEW'WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR [_J OTHER>] V5 50tlo VDI, 3 C�30 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 200 DISPOSAL FLO. MIA PROP. LINE , v FOUNDATION a AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom " ❑ Manteca Dia. of Well Excavation ir1 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type,of Casing pecifications M Public ❑ Other Ll Delta Depth of Grout Seal ^' ype of ou d I I Irrigation _-Approxi Depth l I Eastern Surface Seal Installed by Crr4t1N �D do it t Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l 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 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 LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number 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. 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 must for all requireComplete drawing on reverse side. g 9 Signed X Title: d'// P tr Date: S;Cy _ 00 FOR DEPARTMENT USE ONLY Application Accepted Date At ,,, f..� - Pit or Grout Inspection by Date Find Inspection b Date f Additional Comments: ❑.Stk 466-6781 ❑ Lodi 369-3621 C7 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 I INFO AMOUNT DUE j_� AMOUNT REMITTED CSR RECEIVED BY DATE PERMIT'NO, � +.EH 13-21(MV.1/nsl J�1 I1 •�h1? // EH 11-28 v J