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APPLICATION FOR PERMIT Yyz, y f SAN JOAQUIN LOCAL HEALTH DISTRICT �h� +4 fL > 1601.E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 " ,f . . PERMIT EXPIRES 1.YEAR FROM DATE ISSUED r • ,, (Complete in Triplicate) Application is hereby made'to the San Joaquin Local Health District fora 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 ��✓�s779<.1 City Sim' Lot Size PM + Owner's Name /f�' 77 yfCE 5 Address Phone Contractor_ 15 C"D E• WOeD Address &V X- Al. 6.lt.L/AAl ".6 License No.J��7 G Phone 46V-39-21 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRU BN-'E] PUMP INSTALLATION Q.-.-.--.n- _;--_SYSTEM-REPAIR--C3--w- __ --OTHER'-1Jr --1 DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES POSAL FLD. ? PROP. LINE FOUNDATION - AGRICULTURE WE OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OFiWELL PROBLEM AREA NSTRUCT'ION SPECIFICATIONS w' ��ndustrial C1 Open Bottom 0 Mant Dia. of Well Excavation -- ..Dia.-of-Well Casingbr ❑ Domestic/Private. 1-1GravelPack acy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal = Type of=Grout s by— El Irrigation�y� �Approx. loth ; ❑ Eastern° ; Surface Seal Installed 4 ' Repair Work Dobe ❑ Type of Pump H.P. 5-late Work Done' Well Destruction ❑ Well Diameter Sealing R1laterial (top 501 Depth I 9 Filler-Material_Welow.501 ' ! TYPE-0FSEPTIC-WORK:—NEW INSTAL TION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No•septic system permitted if public sewer is y' avaltabff-W ilii 200-feet'1 i Installation will serve: Residence Commercial Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: — • --- Water table depth69 t SEPTIC TANK C1Type/Mfg ) -- - Capacity, F146-.,,Compartments ' EPKG. TREATMENT PLT. ❑ •.`l;`*- rr is.Method of Disposal - Distance to nearest: ,-Well _ Foundation- _.Prop56rty Line i LEACHING LINE ❑ No. & Length of lines , Total lengthisize FILTER BED ❑ Distance to nearest: I Well Foundation Property Line j t SEEPAGE PITS El Depth Size Number Y `* SUMPS LIP. erty Line Distance to nearest: Well Foundation 7 l r 1 '"""* ro DISPOSAL PONDS ❑ I hereby certify that l 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 became subject to workman's compensation laws of California."Contractor's hiring,or subcontracting 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 c 11 for all required inspections. Complete drawing on reverse side. � Signed 1 ' � Title: Dail": e: � ,. FOR DEPARTMENT USE ONLY I Application 3Accepted by t Date Area-'::a2 Pit or Grout Inspection by _ Date G r Final_ action by ' Date, L, j D0) Additional Comment ❑'Stk 466-6781 ❑ Lodi 36-4-k2i E.Manteca 823-7104 ❑ fricyc ,835-6385 Applicant,-,Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,'Stk., CA 95201FEE . , r _} INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY `! DATE ;PERMIT NO. i +-EH 13-24 IH G.tiu51 � �� EH 1428 (E // FO