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APPLICATION FOR PERMIT SAN JOAQUIN_ LOCAL HEALTH DISTRICT 1601 E. HAZEL TON AVE., STOCKTON, CA Telephone (209) 466-6781 € PERMIT EXPIRES VYEAR FROM DATE ISSUED l (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 jFFF 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 + C1G( 1_P City 45> Lot Size 50,K .5b PM Owner's Name Address" �— Phone Contractor, _`zw*54 Address &k�_License No/I WW C!Phone v/ 3�2 TYPE OF WELL/PUMP:'k-4W—"- NEW WELL ❑ WELL REPLACE NT ❑ DESTRUCTION ❑ PU 1P.4NSTALLATION,0 " „o SYSTEMaREPAIR,rC7 -T - -_: __.__OTHERS❑ — DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES I t DISPOSAL FLD. FPROP. LINE FOUNDATION AGRICULTURE WELL I ltOTHER,WELL, !, ".�P.ITS/SUMPS • INTENDED USE--tYPE-OF-WELt—PROBL-EM•ARFA—.CONSTRUCTION-SPECIFICATIONS *�--�---mm----"�—""�---- � ❑ Industrial ❑ Open Bottom ❑ Manteca Pia. of Well Excavation Dia. of Well Casing t ❑ Domestic/Private ❑ Gravel-Pack`: 0-f—racy Type of Casing Specifications ❑ Public ❑ Other , ,O�Delta Depth of Grout Seal Type of Grout F1 Irrigation _—Ap rox. Depth '46rM5E stern Surface Seal Installed by Repair Work Done ❑ TypeofPumpP. State Work Done I Well Destruction El Well Diameter dealing Material (top 50') Depth -- - --- . _„Filler Material IBelow 501 1 g TYPE OF SEPTIC WORK: NEW"INSTALLATION O REPAIR/ADDITI04 ON ❑ DESTRUCTION (No septic system permitted if public sewer is. available within 200 feet.) Installation will serve: Residence Commercial Other r n Number of living units: Number of bedrooms V Character of soil to a'depth of-3 f ad t.,IT Water table depth r -+:W Y. p f SEPTIC TANK !t * ❑ Type/Mfg Capacity - No. Compartments PKG. TREATMENT�P�L�T�p ""* Method of Disposal Distance to nearest: Well Foundation - Property Line - I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to-nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth I! Size Number SUMPS ❑ Distance to nearest: Well Foundation Property"Line DISPOSAL PONDS ❑ fI 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. Homeowner 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 employ any person in such manner as to become subject to workman's 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." i ' 41 The applicant call fora squired in ctions. Complete drawing on reverse side. Signed Title: /�•�/L'-- Date: a� FO DEPARTMENT USE ONLY Application Accepted '015 Area '015 Pit or Grout Inspectio yDate Final Inspection by I Date Additional Comments: - T� AP ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83548385 Il Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2004, Stk., CA 95201 r 1 FEE INFO AMOUNT DUE AMOUNT-REMITTED RECEIVED BY DATE PERMIT''NO." 71 J//� EH 13-24{REV.t/as) �. O $: v� y/ L�I C"'7(30 EH 14-28 IR