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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (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. Job Address/-O,-5 �O I�. City s Lot Size d d/t SS'PM Owner's Name M�'�GL /Lir Address _`�1eA fir' Phone 6-5-5�e9g I . Contractor ... .... �~- Address License No, Phone TYPE OF WELL/PUMP: I` NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION ❑ t SYSTEM-REPAIR ❑' OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . _DISPOSAL FLO. PROP. LINE FOUNDATION"7—!: _" "v-�AGRICULTURE.WELL OTHER WELL, PITS/SUMPS\ til. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ ibpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private LI 'Gravel Pack ❑ Trac Type of Casing % li, y YP 9Specifications !"I Public ❑ `Oyther. ~- ❑ pelta - Depth of Grout Seal =r-- Type-of-Graut.- I ( Irrigation �H^Approx. Depth I I Eastern Surface Seal Installed by'' -Y Repair Work Done ❑ Type of Pump �. H.P. State Work'pone_ Well Destruction ❑ Well Diameter Sealing Material ftop 50'1 II Depth Filler Material {Below 50') a TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION 11 Wo septic system permitted if public sewer is it, - _ - f,,, 'available within 200 feet_] Installation will serve: Residence Commercial� Other Number of living units: Number of bedrooms ~- II - _ d Character of soil to ai depth of 3 feet: Water table depth v SEPTIC TANK i '- -� _Type/Mfg,, x__ Capacity L �d d j110 Compartments L PKG. TREATMENT PLT. ❑ V r#. r 9 * ` Method of Dispovi Distance to nearest:, Well �2 Fbundation Z0 Property Line LEACHING LINE ( No. & Length of lines '`' io + Total length/size s LTER BEd ❑ Distance to nearest: Well Foundation Property Line %SEEPAGE PITS it Depth '' Size ++ u ber SUMPS Distance to nearest: Well l/ Foundation, ' DISPOSAL PONDS ❑ :11 ' •� Property Line 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 Diltrict. 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 i., employ any person in such mar'ler as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify hat in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- t tion laws df California." , r' The applicant must tali for all required inspections. Complete drawing on reverse side. 9 c' Signed X Title: Date: �l F. DEPARTMENT USE ONLY Application Accepted by Date tea`J t/ a Area Q Pit or Grout inspection by I Date Final Inspection by BC� ` f Date Additional Comments: t El466-6781 EILodi 369-3621 ❑ ant ca 823-71 ❑ Tracy 835-6385 i',' 1 Applicant- Return all copies to:"Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9 01 ` INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED 6Y DATE w ' PERMIT"NO. ;�✓ � +.EH 1�-2e 13-24 EH 1REV.tiK51 1-7<S' �Z/ ��' I � �