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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA ` Telephone (209) 466-6781 }' PERMIT EXPIRES TYEAR FROM DATE ISSUED s (Complete in Triplicate) I` 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 Local Health District. 1 City Lot Size PM Job Address L ' Address �.l.�QUS�dIQr Phone S Owner's Name i+_�st,.—�t'S\ -- Contractor�V1 Address SZ License No. 4f`ir1Clt Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 3C PUMP INSTALLATION Ll SYSTEM REPAIR ❑ OTHER ❑ f •"DISPOSAL FLD. PROP. LINE f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDATION AGRICULTURE WELL OTHER WELL PIT5ISUMPS INTENDED USE' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing Ll Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Type Specifications I ❑ Domestic/Private L1 Gravel Pack ❑ TTracy YP of Casing FI Public 17 Other n Deka Depth of Grout Seal Type of Grout I 1 Irrigation —Approx. Depth i I Eastern Surface Seal Installed by H P State Work Done ` Repair Work Done LJ Type of Pump i� �e A �cn�onwF Well Destruction te Well Diameter M�+ Sealing Material Itop 50'i Depth 115 Filler Material IBelow 50'I �p� � "' j TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION l I (No septicavailable system y temithin relined if public sewer is t Installation will serve: Residence Commercial— Other \ Number of living units: yNumber of bedrooms In Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK © Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well `Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size Property Line FILTER BED ❑ Distance to nearest: Well `'Foundation P Y SEEPAGE PITS I'] Oapth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ - - this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared rules and regulations of the San Joaquin Local Health District. 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 persons subject to workman's compensa- tion laws of California." # The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY wDate: ` Area / Application Accepted by Date Pit Pit or Grout Inspection by Date Final Inspection by s t Additional Comments: I ❑ Stk 466-6791 ❑ Lodi i9636,2210 Ma eca 823-7104 ❑ Tr cy 835-6385 Applicant - Return all copies to: Environmental Health Pefmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' FM' FEE CK RECEIVED BY DATE PERMIT'NO., # AMOUNT DUE AMOUNT REMITTED CASH nr,-% 11,7 /1,•7 + EH 1324(REV.t i n$) 1..�1 (J�r - `• EH 14-2e W 1, _