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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA t Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROW DATE ISSUED r, '°:'Ina'Int a (Complete in Triplicate)� Y. 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. 1962 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. r,; �tflC�`tC7'VlLot Size d k PM Job Address qV City. r w s Owner's Name �a+TYI � l Address" 4 l re - Phone _ f �} I �� rt Pz Contractor 'T ��-� c Address 1 ' T 'r no[ License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 4 �AC r PUMP INSTALLATION ❑ SYSTEM REPAIR LJOTHER V )5c9� loaf 1 q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION 2 AGRICULTURE WELL OTHER WELL""" ____E_ PITS'/SUMPS INTENDED USE TYPE OF WELL! PROBLEM AREA CONSTRUCTION SPECIFIGATIONS;4 I ; ,Industrial-SfOLyrI-�r pen Bottom ❑ Manteca Dia, of Well Excavation l' '� f Weil Casing ❑ DomesticlPrivate ❑ Gravel Pack O Tracy Type.of Casing '� Specifications ❑ Public . E3 Other ❑ Delta Depth of Grout Seal " Type.of Grbut C ❑ Irrigation _-Approx. Dept❑ Eastern Surface Seal Installed yby! T +v,4 " t Repair Work Done _❑ Type of Pum H.P. State Work Done WeII Destruction ❑ Well Diameter .1Z Sealing Material (top 50.) ' Depth T Filler Material iBelow 501: ` TYPE OF SEPTIC WORK: NEW INSTAL TION ❑ REPAIR/ADDITION ❑ DESTRUCTIO ❑ (No septic system permitted if public sewer is available within 200 feet.) AA Installation will serve: Residence— Cam ercial_ Other Number of living units: V Number of bedr ms r.. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑'*'Type/Mfg ' C acity No, Compartments i PKG. TREATMENT PLT. ❑ j4 Method of Disposal Distance to nearest: Well F ndation Property Line LEACHING LINE ❑ No. & Length-of lines ,�„� �..r.m `Total length/size ist FILTER BED ❑ Distance to nearest: Well Fou ation s ' —Property'Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Wel 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, and rules and regulations of the`San Joaquin'-,Local Health District. 42't '0.J ` "' """ •--- 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 shall employ persons subject to workman's compensa tion laws ofyCalifornia."1 L'% The applica st call for all r quired inspections. Complete drawing on reverse side. Signed Title: r )L Date: O D RTMENT USE ONLY V .. Date Are Application Accepted r Pit or Grout Ins ti y ✓` dJFinal Inspection by ate Additional Comments ❑ Stk 466-67$1 ❑ Lodi 369- ❑ Manteca 923-7104 ❑ T cy 835- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009,;Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY , t4. DATE PERMIT`NO. + EH132RIREy.7/e51 EH 1426