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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �J (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 a 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 Cit 3 M Y Lot Size Owner's Name Address N+� G Phone Contracto a Address' L10 s t icense Niel Phone TYPE ,,OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ 3 PUMP INSTALLATION ❑ ' 9�� SYSTEM REPAIR CI OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. : FOUNDATION S G L.---Q PROP. LINE i AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ' PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrialn Bottom ❑ Manteca Dia. of Well Excavation 7- LJ _ Dia. of Well Casing estic/Private '0 Gravel Pack ❑ Tracy Type of Casing�J1 ❑ Public `" - - Specifications L� OtFier Delta""` `' Depth of Grout Seal ❑ Irrigation.` Type o r t Approx. Depth ,�;P Ea ern� Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. ml State Work Dane Well Destruction ❑ Well Diameter Sealing Material (tap 5D') pl I Depth Filler Material {Below 50'1 1Y 3 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is _ rn ' 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: �f SEPTIC TANK ❑ Type/Mfg Waterta_ble_depthCa Capacity— l• # P Y No.-Compartments PKG. TREATMENT PLT. ❑ .1 Method of Disposal I Distance to nearest: Well YFoundatian �^�•;property Lie 4 .' t i LEACHING LINE ❑ No. & Length of lines I Total length/sizet�. FILTER BED; El Distance to nearest: Well Foundation rx Property Line SEEPAGE PITS ❑ Depth Size e Number t SUMPS ❑ Distance to nearest: Well Foundation, Property Line i § DISPOSAL- PONDS ❑ i 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. t rs Hdme owner or licensed agent's signature certifies the following: "I certify that n the performance of the work for which this permit is issued, 1 shall not /1, employ any person in such manner as to become subject to workil%67s 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." 4 The applicant must call for all required inspections. C qpIete,driawing on reverse side. Sined X � I tea t Title: Date: Za �J FORWEPARTME11l�fi;��SE ONLY Application Accepted by ^" r Q B ,",'<:..; Date '�-» ` iiea'`. Pit or Grout Inspection by bateFinal Inspeciion,.tiy" ' ? / 1. 7 — Dat -72 Additional Comments: -`;kcz'' p Stk 466- 6781 ❑ Lodi 369.3621 `, ❑ Manteca 823-7104 N,`'I❑Tracy 835 6385 K f('Applicant-,Return all copies'to: E6i6nn enthl Heaith-Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 If 6FEE'. AMOUNT DUE-'` AMOUNT REMITTED"" RECEIVED BY " CASH " " INFO DATE PERMIT"ND. + EH 13-24(REV.I/a 51 .y.EH 1428