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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 C 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. a y + `�� ! S ' 0at! -1��a y�� ' A Jab Address JU City GUrt l,r Lot Size 'Z PM Owner's Name 90Cv - = Address A Phone � Contractor e,I t � ''S W J3V,1�`r - Address� a l7 o, License No,3J 3 d- _ S Phone 33 Y-9 7 Z s- k TYPE OF WELL/PUMP: NEW WELLX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION` SYSTEM REPAIR ❑ OTHER ❑ III DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION --- v AGRICULTURE WELL .. -OTHER-WELL- _PITS/SUMPS- INTENDED ITS/SUMPS-INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI01�5 .� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing +'Domestic/Private Gravel Pack ❑ Trac g Specifications ❑ Public Y Type of Casing �T < ❑ Other ❑ Delta Depth of Grout Seal S S C ❑ Irrigation ! ��A Type of Grout pprox, Depth ❑ Eastern Surface Sea! Installed by N 1- Repair Work Done ❑ Type of Pump SL,00 H.P. ! State Work Done Well Destruction ❑ Well Diameter Sealing Material /top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK. NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is � Installation will serve: available within 200 feet.)_Residence_ Commercial i Other ' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth V SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 711Method of Disposal +?+ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS ❑ Depth Size Number `�-SUMPS" ----- ❑ Distance to nearest: Well Foundation " Property.Line -�- DISPOSAL PONDS ❑ rules and regulations of the San Joaquin Local Health District. 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 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 Y 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 x rr., t it at.. Title: Date: FOR DEPA TMENT USE ONLY Application Accepted by Date Area r PitGro 0.nspection by Date Final Inspection by Date . Additional Commerit_s: ' ❑ 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 r 4... FEE 9 .9n ` INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. ER 3-24 X EH 14-25 /ti�O.\ �` cJ-�$ C/ Cl '7�{� PV X9/7