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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 Address v (/! /a w Srzeeor City sSn c k2nF L._ Lot Size PM dN -IAIJ7=.4 �F ,AtA,7.4 7 . .`213 Owner's Name Address _1.�.>I A/Vtr.6� 3 R 904�j__0 _ Phone p , 1�✓I/ewes .3"663 BMfic ��'Rcc�, sur r� 9/6 Contractor 1P1-�,�iil/l �•, �iV ddress AoAP�e e5 License No. SI�y�S Phone s TYPE OF WELL/PUMP: NEW WE L ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ PUMP INSTALLATION S STEM REPAIR El C�}' r-0/4 .BDI[I�/Vt S DISTANCE TO NEAREST: SEPTIC TANK SE ER LINE DISPOSAL FLD. PROP. LINE FOUNDATION A RICULT E WJFLL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE `AREA N UCTION'SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. of ell Excavation Dia. of Well-Casing FI Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications nPublic Cl Other Cl Delta e of Gr t Seal Type of Grout I ] Irrigation Approx. Depth I Eastern urface Se'I Instal d by Repair Work Done 11 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Materia p 5('1 Depth Filler Material /Bel TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION l I D S RUCTIO I i 1No septic system permitted if public sewer is available within 200 feet.) 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation operty Line LEACHING LINE ❑ No. & Length of lines Total length/ � e FILTER BED ❑ Distance to nearest: Well Foundation Prope Line SEEPAGE PITS I I Depth Size Number SUMPS L7 Distance to nearest: Well 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 cbu ty ordinances, state laws, and rules and regulations of the San Joaquin Local Health Diltrict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this ermit is issued, l shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or ub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject t workman's compensa- tion laws of California." The applican t tali for all requ' inspections. Complete drawing on reverse side. Signed X Title: �r, )fez 62y/f'011. i it eJnate: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. +.EH 1324(REV.i/n5) FH 1428