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' - 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 (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 Distric� �N, ,�� r . - [, S6Zt_�-70-02q8`yf � V+ -,T- a F T-5 And '0-7 r.-17 0 -nS Job Address T� 5� 7 SnuT ti DF R Czes-K �o. 671-17 0 --0 y ��C`itY � Lot Size PM Owner's Name BA 561-L' 4VP �. Address :9-14 AVV- P-CN 4A^!e 1 .�� Phone � �l-5- 7$ Contractor ! CJ9 ?RTS Addres L f7� 0MI License No. (ob z`7C� Phone 4!b 37l-16 v TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS El7 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS X77-mrauk,u� eQk l . Ed Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation :U)l Dia. of Well Casing �. L1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public LJ Other {1 Delta Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth l I Eastern Surface Seal Installed by " Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION (_I DESTRUCTION I I (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial_ Other available within 200 feet-) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: j Water table depth F SEPTIC TANK LJ Type/Mfg Ca acit t P Y No. Compartments PKG. TREATMENT PLT, ❑ ._ Method of Disposal Distance to nearest: Well Foundation y vI Property Line 1 S' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I Pli SEEPAGE PITS I I Depth Size Number SUMPS 0 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 laws, an 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 shalt not e performance of the work for which this permit is issued, I shall employ persons subject to employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signatur certifies the following: "(certify that in th tion laws of California." workman's compensa- The applicant ust call for all required inspections. Complete drawing on reverse side. Signed X � Title: r ( +"CIf� -66 8a Date: i FOR DEPARTMENT USE ONLY Application Accepted by Date 45— Area Pit or Grout Inspection by Final Inspection by 'p Date Additional Comments: hill �Z Co ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 P Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE EllN0, EH 14-24{REV.t/H51 3S�'. � �7Q ��