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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) 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 Addres _� 9C11IlJ y - _ City Lot Size PM Owner's Name R KU5+4 ,Address Phone Contractor Address '7 7_13 Y0K P.2_, License No. qPhone?A1 11§ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO N REST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FO AGRICULTURE WELL 01H S INTENDED USE TYPE OF WELL PROBLE CON ION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. o avation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack cy Type of Casing Specifications \ 1-1 Public Cl Other f-1 Delta Depth of Grout Seal T pe of Grout +� 3 Irrigation prax, Depth I i Eastern Surface Seal Installed by _ t� Repair Work Done Type of Pump H.P. State Work Done 1 Well ion ❑ Well Diameter Sealing Material {top 50'I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTIONW-(No septic system permitted if public sewer is � available within 200 feet.I— Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth CL SEPTIC TANK ❑ TypelMfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size , FILTER BED ❑ Distance to nearest: Well Foundation Property Line M SEEPAGE PITS l I Depth Size Number { SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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." Contractors 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 Calif ia." The applicant t call fprWqdinspections. Complete drawing on Signed X _ Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by _-. bate � �--r Area Pit or Grout Inspection Date Final Inspectiop by Date 1-7 Additional Comments: r`'� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t��Yu7 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ( / N 0+, s O t J f 4 h a P11-101L, r G v,.,_.�} f'I d f 4✓ii l abt l r^M 0 FEE INFO AMOUNT DUE AMOUNT REMITTED �C(ASH CK RECEIVED BY DATE PEERRfMIT-IVO. a.EH 14-24 1REV.1 i 1151 f v �� /I Ira / �� J/ —/ EH 14-28 J )11111 l! 4` /�-/ Ea