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APPLICATION FOR PERMIT 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 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. t Job Address �0 City $ Lot Size PM _Owner's Name J0Ai17 r Address ` u'60 /kyr I Phone p' C' 23 Contractor Z^1 t- l-"D,17/l//St. 4 Adiiress�eQ:, _C . License-No.ics'-76 i Phone { TYPE OF WELL/?UMP: NEW.WELL,-� _�_',WELL REPL,4CEMENT ❑ _DESTRUCTION ❑ PUMP INS ;ALLATION . ` SYSTEM.REPAIR_0. . r. OTHER.:El DISTANCE TO NEAREST: SEPTIC TANK I�(06__ts' SEWER .LINES Jam '� DISPOSAL FLDo3 PROP. LINE r 60 j FOUNDATION' V AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF.WELL PROBLEM,AR EA CONSTRUCTION SPECIFICATIO S z1 . LI:Industrial ❑ Open Bottom "i Manteca, Dia- of Well Excavation 1 Dia. of Well Casi g s,.,. - _.. 255 /.6 0 FX,Domestic/Private _X Pack ��--D Trac .._Type of Casing V�— 5pecificationsC r [11Public a C� Other �` ,--N Delta -—Depth- Grout Seal ArD Type of Grout N�y 'CCl-h®re.r I I Irrigation 0-6—Approx. Depth I I Eastern Surface Seal Installed by II Repair Work Done ❑ Type of,Pump H.P. State Work Done Well Destruction ❑x Well Diameter I Sealing Material Itop 50'1 r Depth Filler Material iBelow 501 TYPE OF SEPTICtWORK:' NEININSTALLATIONtI I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence_ Commercial— Other 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. 0 Method of Disposal Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. & Length of lines Total length/size F FILTER BED ❑ Distance to nearest: Well Foundation Property Line i I SEEPAGE PITS 11 Depth Size Number. } SUMPS f ❑ Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS ❑ I I f ereby 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 fallowing: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." ' The applican u call for required inspections. Complete drawing on reverse side. ` I Silned XTitle: lac -L—J.P1 Date: 7 r J I .FOR DEPARTMENT.USE.ONLY, Application Accepted by4f r Date ��5- Area r Pit or Grout Inspection b Dater r Final Inspection by Date - Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 1335-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-24(REV.1/µ5) 1Q�`�_ /uJY' / /l 21—x—0 ff EH 14-26 VV —/7S`F