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Y l APPLICATION FOR PERMIT T— S SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA l Telephone (209) 466-6781 _ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED R. (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 . A 0 TC tv Lot Size PM Owner's Name ARA4 X l 4SM'91,Address �-3 7 Z/, 7 :5 � - _ Phone I a Contractor �L>�` si' Address -S�A/-1(Z- License No. Phon l TYPE OF WELL/PUMP: %NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMf?INSTAL N ❑ SYSTEM REPAIR ❑- OTHER Ll: f' DISTANCE TO NEAREST:w ,SEPTIC TANK. ? SEWER LINES DISPOSAL FLD. PROP. LINE [� ' ' Lv r� J FOUNDATION ``AG URE WELL OTHER WE ITS/SUMPS INTENDED USE TYPE OF WELL' PROBLEM AREA CONS TCIFICATIONS (` ❑ Industrial ❑ Open Bottom ❑ Manteca ell Exca - n Dia. of Well Casing V ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications ❑ Public ❑ Other r elta Depth of Grout Seal Type of Grout ---0 Irrigation, , .. .-_..A epth LJ , ,:Surface Sea! InstalEed by Repair Work Done ❑ ,Type of Pump H.P. State Work Done_ Welt Destruction ❑ 'Well Diameter Sealing Material (top 50') I -DepthFiller Material (Below 50') j TYPE OF SEPTIC WORK: NEW}INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No;septic system permitted if public sewer is a ailable within 200 feet.) Installation will serve: Residence— Commercial— Other J7 , ��..// j Number of living units: ,Number of bedrooms Character of soil to a depth3 feet: Water table depth I SEPTIC TANK >` Type/Mfg Capacity No- Compartments } ; PKG. TREATMENT PLT. ❑ I I Method of Disposal ? Distance to nearest: Well Foundation Property Line. d LEACHING LINE ❑ Not& Length of lines Total length/size f FILTER BED ❑ Distance to nearest: Well Foundation Property Line E SEEPAGE PITS Depth Size Number SUMPS ❑ - Distance to nearest: Well Foundation Property Line .DISPOSAL PONDS Q 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 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 hall employ persons subject to workman's compensa- i tion laws of Califor is-", `€ ._ +rers-e i tom„Y E F Thea licant ust ca for a I'required i pec ons. Completee. f`�Signed XW� Til ' Date: `-'OR pEPAE ONLY j Application Accepted by OA. Y Date C]� Area Pit or Grout Inspection b Date Final.Inspection by Date a �� Additional Comments: y ❑ Stk 466-6781 - ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O..Box 2009' Stk., CA 95201 n I FEE INFO AMOUNT DUE AMOUNT REMITTED C K H RECEIVED BY2 DATE PERMIT'NO�' + EH1324[REV.1/N 5) + £H 14-28