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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 _ � PERMIT EXPIRES 1 YEAR FROM DATE'I h SSUED (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 ' 4 1/V1 /9�it'.�� City Lot Size PM Owner-s-Name��J �+�Z, (r?�/�/�� -- Address PhoneU Tg� '•a ContractorAl, Address-y' / License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: .SEPTIC TANK _ SEINER LINES DISPOSAL FLD. PROP. LINE FOUNDATION # l AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE,OF WELL, PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial `❑ Open''Bottom f ❑ Manteca Dia. of Well Excavation Dia. of Well-Casing ❑ Domestic/Private ❑Gravel Pack ❑ Tracyt Type of Casing 5pecificatrons M Public F1 Other 1 #f Delta 1 Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth .I I Eastern Surface Seal Installed by Repair Work Done Cl Type of Pump H.P. iState Work �pon ,_ r - WiiII'pestruction ❑ Well Diameter Sealing Material (top450') 4 LA Depth t P .Filler Material 16elow 50') 0n TYPE OF SEPTIC WORK: NEW INSTALLATION)K) RFPE IR/ADDITION l I /DESTRUCTION I I INo septic system permitted if public sewer is V f , available within 200 feet.) Installation will serve: Residence_ Commercial X Other 45umber of living units: Zpa Number of bedrooms kA -Character of soil to a depth of 3 feet: a Wa.ter table depth SEPTIC TANK 10( Type/Mfg QA Wr JS44. Cas � �O tmentsCompar - - # PKG.-TREATMENT PLT. 171 /~�- Method of Disposal Distance to nearest: Well Foundation—L G�, Property Line f0 f I � LEACHING LINE ❑ 'No. & Length of lines Total length/size— �adD Y / r J FILTER BED IDistance to nearest: Well Foundation �D � Property Line §,__ SEEPAGE PITS l I ;Depth Size Number SUMPS L� Distance ton_nearest: Well Foundation Properly Eine DISPOSAL PONDS ❑ I-hereby certify that i have prepared this application and that the work will be"'done in accordance with Sari Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Dilarict. Home owner or licensed agerit's signature certifies the following: "I certify that i6 the performance of the work for which this permit is issued, I shall not employ any person in such manneras.to.become-subject to workman's compensation laws of California-" Coritractor'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:" I The applicant must c I for all re ui ed inspections. Complete drawing on reverse side, r Signed X � Ti e: Date: r EPARTMENT USE ONLY Application Accepted byate a �' A Area Pit or Grout Inspection by Dat Fig�aL Inspection by to l Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑" rT acy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601:E. Hazeltoh Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED Y CASH-CK 11 RECEIVED BY DATE ' PERMIT-NO. + EH13-21(REV,t i n 51 EH 14-26 (t•/ I CS JCS/9 L Y -t x