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f APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 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 r made in compliance with San Joaquin Cbunty Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin I4 Local Health District.. 4 Job Address J 3 o�Y IV,,i a!? 0'r41100713 y� t I City 4!7! �f4 Lot Size PM Owner's Name A6V 4otar - �/ fHress — A7 �iTeccr � / Phone Contractor lir �1"et ddress DS'70 i(far, Y�t�S'73 Phone License l�io. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR L1 OTHE DISTANCE TO NEAREST. EPTIC TANK �`z� SEWER LINES DISP PROP, LINE FO ATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �� ' INTENDED USE TYPE OF W PROBLEM AREA STRUCTION SPECIFICATIONS (I ❑ Industrial ❑ Open Bottom ❑ a Dia. of Well Excavation C] Domestic/Private ❑ Gravel Pack Tracy 1-1y sing Dia. of Well Casing {'1 Specifications Public Cl Ot { }❑ DeltaDepth of Grout e Type of Grout _ I 1 Irrigation --Approx. Depth I'll. Eastern Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump{} r H.P. State Work Done Well Destruction ❑ Well Diameter • 'Sealing Material (top 50') s ` Depth - t=iller Material (Below 50') II TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION LI DESTRUCTION (No septic system permitted if public sewer is Installation will serve: Residence j Commercial i Other available within 200 feet./ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth �} SEPTIC TANK ❑ Type/Mfg Ca acit PKG. TREATMENT PLT. ❑ p Y No. Compartments Method of Disposal Distance to nearest: Well FoundationProperty Line t LEACHING LINE ❑ No:_& Leng[h of lines I Total length/size t e FiLTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth• V ' a ' Size Number SUMPS ❑ 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 Eaws, a 1 rules and regulations of the San Joaquin Local Health District. N Home owner 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 tion laws of California." r p Y persons subject to workman's compensa- The applicant must call for all required ins r q pections. Complete drawing on reverse side. Signed X - p�y r itle Cgg& O bate: '_S— FIRR DIZARTMIENT USE ONLY Application Accepted by I % _ Date Area Pit or Grout Inspection by 4 Date # F nal inspection by I 1 , Date r i Additional Comments: �" �, r�� ❑ Stk 466-6781 ❑ Lodi 369-3621 Oanteca ,823-7104— ❑ Tracy 836-6385 �c�o .PciG F Co°n��c r-a /r.rFjfi Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O., Box 2009, Stk., CA 95201 oFiF',Pi�F( Q ��• FEE gT DUE AMOUNT REMITTED CK INF CASH RECEIVED BY DATE PERMIT'NO. + EH 13-241 1HEV,t i rs 51 Q EH 14-28 >f 1