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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 1 `]'f 'f r�1/1// City ��L,4L Vt Lot Size �/1� r /^ PM Ownerm Owner's Nae (_Q✓'n ri Ri u- -An Address C Phone Contractor = P Address iS- Ar oId 0q "" License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION EDSYSTEM REPAIR [IOTHER �e4 ZA C){ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 3o,-( lodrl n9 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Indusbial'S Qrt4-b)r pen Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/PrivaGrovel Pack ❑ Tracy Type.of Casing te Dia. of Well Casing S ❑ Public ❑ Other Peciacations ❑ Delta Depth of Grout Seal Type of Grout Irrigation Type Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTAL TION ❑ REPAIR/ADDITION ❑ DESTRUCTIO ❑ (No septic system Permitted if public sewer is Installation will serve: Residence_ Com rcial_ Other available within 200 feet.) Number of living units: _ Number of bedr ms Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth ❑ Type/Mfg C city No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well F ndation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Fou tion Property une SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to merest: We Foundation Property DISPOSAL PONDS ❑ Lim 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 sub-contracting 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 appl call for all r wired inspections. Complete drawing onn reverse side. Signed 0 1 Title: y 1_.t t 1 9 t- FnC www U A Data: r O D FITMENT USE ONLY 0 Application Accepted Date ��Z4 Area Ph or Grout I `� r — Final Inspection by Date Additional Comments ((J a ElStk 486-6781 ❑ Lodi 3� ❑ Man ace 823-7104 ❑ T cy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INr-O L RECEIVED BY \, DATE PERMIT NO. Lf t4 x.21 IaFY.i e 1 J O 1 1 Z�p/ ID