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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT X1 1601 E. HAZE T ON AVE., STOCKTON, CA w Telephone (209);466-6781 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 Co'u my Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. tr Joh Address AT/S rLl tz .7Z°9 .4 e/c City 5 r74A- Lot Size 7-Ck IV n PM Owner's Name .Stlf/zt/ /4t_ Address 6 Phone f Contractor GGD yz) -Address.-�FNr 94_>eZ-4_,�--A7- _License No.4�2-. 1-14 Phone ' 3577 _ TYPE.OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM PAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE FOUNDATION- AGRICULT '1NECL OTHER-WELL PITS/SUMPS INTENDED USE _ TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS y ❑ industrial ❑ Open Bott mZDc Dia. of Well Excavation Dia. of Well Casing (\ ❑ Domestic/Private -❑ Gravel Pack' Type ofCasing I Specifications ('1 Public (_1 Other Depth of Grout Seal I Type of GroutI I Irrigation —_Approx. DSurface Sea! Installed byRepair Work Done ❑ Type of PumpP- Slate Work DoneWell Destruction ❑ Well Diameteraling Material (top 501 F \ Depth ! Filter; Material (Below 501 TYPE OF SEPTIC WORK:.. NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION Mo septic system permitted if public sewer is (� r , ; •avajlable within 200 feet.i `�?4 Installation will serve:' Residence Commercial 1�`1,.Others ' t Number of living units: Number of bedrooms - Character of soil to a depth of 3 feet:�: 1. t Water table depth SEPTIC TANK ❑ T I ypelMfg" Capacity No. Compartments ` PKG. TREATMENT PLT. ❑ Method of Disposal `-'I } Distance t1 nearest: Well Foundation Property Line LEACHING LINE �❑ No. 8 Length of.lines I Total length/size j FILTER BED ❑ Distance toFnearest: 'EWell •LA Foundation , Property Line SEEPAGE PITS 11 Depth `Size t ,! Number SUMPS D 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'Disinct- �I I Home owner or licensed agents signaturle'eartifies the following: "I certify that in the performance of the work foe which this permit is issued, I shall not employ any person in such manner as to 1. subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in tfie 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 call for all re uired inspections. Complete drawing on reverse side. 1 _ + Signed X Title: Date: FOR DEPARTMENT USE ONLY 44 Application Accepted b pP P Y . Date Area Pit or Grout Inspection by Date Final Inspection by Date / Additional Comments: /�y ❑ Stk 466-6781 IJ Lodi 369-3621 . ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to:-Environrr6tal Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 n ,! 1 CK FEE INFO AMOUNT DUE AMOUNT REMITTED Cp�SHg RECEIVED BY DATE �7 �PERMIT—NO-71 + EH 1 .241REV. / l /l• /� �a/ Y,� //7U Elf 144-28 �/'`