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�5 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I€cation is Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. This app' made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. ?� ' _ City Lot Size PM r Job Address -� -,--.-- i Owner's Name � �J _ Address Phone Contractor ss S• ense N Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTS DESTRUCTION ❑ PUMP INSTALLATION C SYSTEM REPAIR 11 OTHER ❑ --w& .DISTANCE-70 NEAR ESTLSEPTICrT.ANK, RDF/ SEWER LINES „ DISPOSAL FLD./00-ff_PROP. LINE,/JP/ } FOUNDATION "-AGRICULTURE WELL WELL - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 75� { Type of Casin S Specifications .Domestic/Private n Other Pack ❑Tra� � yp g f"1 Public nf_-f�eO/5ther 4�17t� Depth of Grout Sea{ Ili}7F77-7:- Type of Grout I 1 Irrigation -2C2.Approx. Depth i i I Eastern R- Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. t T-f I - ork Oone .-- - State W Well Destruction ❑ Well Diameter a Sealing Material Itop 50'i t Depth ! Filler Material (Below, ' 50'I -- rt TYPE OF SEPTIC WORK: NEW INSTALLATION I'i REPAIR/ADDITION I I DESTRUCTION l 1 (No septic system permitted if public sewer is N r avaiiab within 2p00 fe t.) S Installation will serve: Residence Commercial— Other ' // II ` P s Number of living units: Number of bedrooms ( �y �Gi Character of soil to a depth of 3 feet:+ I t I Wa table depth SEPTIC TANK ❑ Type/Mfg t � _` Capacity No. Compartments PKG. TREATMENT PLT. ❑ �� Method of Disposal f Distance to nearest: Well W "Foundation Property Line LEACHING LINE ❑ No. &'Length of lines s Total length/size FILTER BED ❑ ,Distance t`io nearest: Well Foundation Property Line SEEPAGE PITS I I Depth-J ? Size Number SUN1pS zz _." 'C1—Distance to nearest:' Well"!f!t�FounddtiW-- Property Line' y DISPOSAL PONDS El 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 ce ify that in tfe performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." 'S ' The appl' t st f all re i d inspections. Complete drawing on r se side. Signed X Title Date: - FOR DEPARTMENT USE ONLY Application Accepted by Date Area fL D on Pit or Grout Inspectib Date Final Insp ction by Date Additional Comments: � '" � Cl Stk 466-6781 ❑ Lodi 21. ❑ Manteca 823-7104 ❑ Tracy M-6385 Applicant - Return all c pries to: ITHealt Per rt/5ervi s/1601 E. H elton Avp., P.O. Box 2009 Stk , A 95201 � FEE AMOUNT DUE' AMOUNT REMITTED CASH RECEIVED BY OATS PERMIT NO. INFO +.EH 1324(REV.i/e sf �J�1 EH 14-26 r