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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT J 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED Q�ao6^A_Kt % (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. 7 3rZA Job Address &' i%--) City '� Lot Size PM i .-- • � {rf!es� �j,, ^-7 ^� Owner's Name�A IFG� I Address v�� !�+} /^ C 2 e'f ) +Phone Contractor 1 Address 5_�2D �tfZ��Cf j�� License No. Phone TYPE OF WELL/PUMP: NEW WELLi-❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:`SEPTIC TANK SEWER LINES POSAL FLD. PROP. LINE FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS j ❑ Industrial ❑ Open Bottom ❑ eca Dia. of Well Excavation Dia. of Wel! Casing ❑ Domestic/Private ❑ Gravel Pack Tracy- Type of Casing Specifications f`l Public �l Other Cl Delta Depth of Grout Seal Type of Grout _ *I I Irrigation I_.. pprox. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump' H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 50') 1 •` , TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION 11. DESTRUCTIONA IN septic system permitted if public sewer is w r available within 200 feet.) U Installation will serve:` Residence_____' Commercial— Other f Number of living units: Number of bedrooms I' ` Character of soil to a depth of 3 feet: M Water table depth SEPTIC TANK + ❑ Type/Mfg Capacity *" No. Compartments PKG. TREATMENT PLT. Q f . Method of Disposal Distance to nearest:. Well Foundation 4 Property_Line- - -- i LEACHING LINE ❑ No. & Length of lines Total lengtfl/size 1 + h FILTER BED EI 'Distance to nearest: Well ' Foundation' P operty Line SEEPAGE PITS I1 ,Depth ""Size "'" "Numbet x I s SUMPS / ❑ g Distance to nearest: Well • ., � Foundation Property Line f 3 DISPOSAL PONDS F) _ 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 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,1 shall-employ persons subject to`wotkman's compensa- tion laws of California." y The applicant ust all for all required inspections. Complete drawing on reverse side. I Signed X y Title:' O� ryi Date: =12 RTMENT USE ONLY Application Accepted by IMlzaL-LQ . Date � U� Area _ y Pit or Grout Inspection by Date Final Inspection by Date O Additional Comments: /, G Ckn,,IC ® 2R 1 S e ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 6385 Applicant,- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P-O. Box 2009, Stk., CA 95201 x FEE . f INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH13-24(REV,iinsY ' EH 19-2e ^+ -