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APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2W 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED (Complete in Triplicate) t 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 .� .� City -4-*Y f Lot Size I-Ae /I.176Z PM Owner's Name tllfff'.C'i Lid ./�✓ 44VW ddress s Phone S46 7 "41 Contractor's Name ,�'/ , '/E`lYAl !"lf� License No. Phone G6— V40-7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑_Public% , ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Sea! Installed by Repair Work Done ❑ Type of Pump H.P. i State Work Done _ s Well Destruction' ❑ Well Diameter Sealing Material (top 50') � Depth - Filler Material (Below 50') f C) TYPE O-F SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION El DESTRUCTION El (No septic system permittedifpublic sewer is available within 200 feet.)_'_'. Installation will serve: Residence_ Commercial— Other Number of living units: — Number of bedrooms p Character of soil to a depth of-3 feet: - ✓ p * �"" Water table depth SEPTIC TANK C�Type/Mfg . 'fag ori,✓.F/V Capacity—ie Q9 No. Compartments PKG. TREATMENT PLT. ❑ J Method of Disposal Distance to nearest: 4.Well_"d Foundation 26 Property Line /00 0 LEACHING LINE © No. & Length of lines Total length/size r FILTER BED Distance to nearest: Well A 049 Foundation_._�� Property Line SEEPAGE PITS -1.s .❑ Depth Size Number SUMPS ❑ Distance to nearest: --Well Foundation Property Line �..Y 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. y 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,!shall employ persons subject to workman's compensa- tion laws of California."The applicant call for all required insp�17&_ . Complete drawing on revs side. Signed "'LTitle: ,..... Date: +� FOR DEPARTMENT USE ONLY Application Accepted by Date Area 01 PR or Grout Inspection by `+ ` Date Final Inspection by �� ___ Date Additional Comments- $ •r i `� ❑ Stk 466-6781 El-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 5 1INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +EH13-24{R 10!831 EH W26