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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 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 City Lot Size PM _4 Owner's Name �~J IniF Address j Phone Contractor Address icense No. Phone_ r TYPE OF WELL/PUMP: NE WELL.❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ � I t DISTANCE TO NEAREST: SEPTIC TANK w SEWER LINES DISPOSALIFLD. PROP.:LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/S PSS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t El Industrial ❑ Open Bottom ❑ MantecaDia. of Well Excavation Dia. of WelhCasing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications y YP 9 _ F1 Public _ 171Other ❑ Delta > `'. Depth of Grout Seal Type rof,Grout I I Irrigation ..Approx. Depth I I Eastern_ Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P.1 State Wark Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'I j y. Depth Filler Material {Below 50 31 A TYPE OF SEPTIC WORK: NEW INSTALLATION-1-1—REPAIR/-A DDITIGN-i-l—DESTPUCT-ION- •1..I.No:septic=system•permk4ed.if-public-sewer is t f available within 200 feet.) m Installation will serve: Residence �_! Commercial Other r.e Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ! PKG. TREATMENT PLT. ❑ rMethod of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE. 0 No. & Length of-lines Total length/size F FILTER BED y ❑ Distance to nearest: Well Foundation Property Line 4. S SEEPAGE PITS I 1 Depth Size Number i SUMPS ❑ Distance to nearest: Well Foundation Property Line t� DISPOSAL PONDS L1- 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 certify that in the performance of the work for which this permit is issued, I shall not I employ any person in such mariner as to become subject to workman's compensation taws of California:"Contractor's hiring or sub-contracting signature i certifies the following: '9 certify that in the performance of the work for which this permit is-issued„Lshall-employ persons subject to workman's compensa- tion laws of California.” - F The applicant call for all required inspections. Complete drawing on reverse side. Signed4A60 h, Title: 0A_AnA Date: >±�, FOR DEPARTMENT USE ONLY �� a iApplication Accepted by Date � �4 `c. _ Area ' Pit or Grout Inspection by Date final Inspection by e114 , 2-9— Date dditionaf Comments: - IStk 466-6781 ID Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 /` tom.✓ pplicant Return all copies to: Environmerital¢Flealth-Pe Trit15'e�vi 1601-E.Haielton Ave:; PCO: B�2009,'S1k CA 95201"°` V iy- ' FEE AMOUNT DUE .#,AMOUNT'REMITTED�J '.CASH' RECEIVED 9Y `> DATE��- PERMIT'NO. INFO r - j � ar _ -� .. r G� / ♦ EH 13,24 IREV,1'H51 _ .r yeV�� •.i..�+. -- _.� T .,... o - {. uo EH 14=28•_.ir.:^m"..^'.: �. ��