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. j APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-Ml 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin k Local Health District. `. Job Address _?�'�� `0 �� ' ` Cid G Lot Size PM r Owner's Name ddress �Z /�_/`//7� ' Phone 3 �eq Contractor QQ i Address License No.�Phone TYPE OF WELLIPUMP: vNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK Vj, SEWER LINES DISP05AL Ftt�rrD PROP. LINE FOUNDATION[~. AGRICULTURE WELL OTHER WELC�— PITS/SUMPS INTENDED USE TYPE OF WELL ENI AREA• -CONSTRUCTION-SPECIFICATIONS ❑ Industrial ❑ Open Bottom Ch Manteca Dia. of Well Excavation Dia.,of Well Casing ❑ Domestic/Private 11 Gravel Pack�j ❑, acy Type of Casing Specifications Public ' L1Other T ❑'Beata Depth of Grout Seal Type of Grout C1Irrigation ---Approx. Depth'�f�, East,6rn Sulrface Seal Installed by Repair Work Done El Type of Pump t_� H.P\. ! State Work Done ��ILL 5 USI C,EJ�' Well Destruction ❑ Well Diameter `-1 ; ealingtMaterial {top 50'i _ Depth 0 i ller Material (Below 50') .tTl /I//J2�L /7S) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RE AIR ADDITION ❑ DESTRUC"[ION-❑..(No septic system permitted if public sewer is ^-- available within 200'feet:)��I Installation will serve: Residence Commercial -_ Ot r Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: l Waterta"tild-depth SEPTIC TANK Q Type/Mfg Capacity No Cl.mp'a7tments k PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: AWellFoundation Property tine 1 LEACHING LINE ❑ No. & Length of lines Total length/size a FILTER BED ❑ Distance to nearest: Foundation Property Line I i SEEPAGE PITS ❑ Depth!j Size -Number SUMPS El Distance to nearest: Well 1 ,Fo` ndation Property tine 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 District. } Home owner or licensed agent's signature certifies the following: "I certifthat inithe 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 co pensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for whi h this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California. r j `' The applicant f all re pections.Complete drawing on lever se e. �, ' Signed Title; ��'' Date:- r.. pr FOR DEPARTMENT USE ONLY -� :.- a� -A. I Application Accepted b Date `Area < Pit or Grout Inspection y ! Date Final Inspection by v: Additional Comments: ._. ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 "a FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO jj + EH 13-24 IREV.1/B 51 � C� � �Y17S6'`O 5-71 �, EH 14-28 - I{