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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA E ,, , Telephone (209) 466-676+--- PERMIT 66-676+—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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �I C`C �' City E �r"' Lot Size �S X PM Owner's Name wdA010Z%7,4 CSW r Address ``G�"� ".. ._.___ Phone Contractor Address —.260 V —License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER 71DISTANCE TO NEAREST: SEPTIC TA SEWER LINES SPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tr Type of Casing Specifications 1-1 Public ❑ Other _ elta Depth of Grout Seal Type of Grout I I Irrigation _._Approx. De I I Eastern Surface Seal Installed by Repair Work Done LJType of Pum H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Mater Stop 501 Depth Filler Material (B ow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l 1 DESTRUCTION VNor septic system permitted if public sewer is available within 200 feet.} O 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 L� 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 Di§trict. 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 t for a re inspections. Complete drawing on reverse f^side. f Signed X -7 4 Title: � C.,` Date: f FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspectio y _ Data Final Inspection by v Additional Comments: El Stk 466-6781 L1 Lodi 369-3621 ❑ Manteca 823-7104 - Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY / DATE PERMIT'NO. +.EH t3-24 IAEV.v/x 51 ��, �� EH 14-2e v �{1X