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APPLICATiC,f'N F6R 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 lCornplete 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. .T� mo, f70el Job Address City�f Lot Size PM Owner's Name U�S A 811/15ION 0IC' Address IINg SH4 1k) )904,6 Phone 7D 9—g`/p –30315— /V LII 1 CHd_M 109 L CO. 12 Attic HD cowbcvip � Contractor T -Address 3 FlT��Ct2g1_t� License No. �S�{R7� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X _011-1 V0GS (4�) DISTANCE TO NEAREST: SEPTIC TANK > SEWER LINES >I 00 DISPOSAL FLO.'2 IOD PROP. LINE FOUNDATION �,' I bL'7 AGRICULTURE WELL?_l Od OTHER WELL 2 0D__ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. ofan Ib } Dia. of Well Casing C) Domestic/Private ❑ Gravel Pack t� 171Tracy Type of srti7� Specifications ri C1 Public Other-r651OLE ❑ Delta Depth of Grout Seal Type of Grout C1E$ G SAI(3 I I Irrigation —().Approx. Depth I I Eastern Surface Seal Installed by Re air Work Done ❑-r,K5r "tpt.+.]1�`T't� p ype of um H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 p„ TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l 1 DESTRUCTION l I (No 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 pis )sp�a�l Distance to nearest: Well Foundation Property line P,�Y E NTIME D LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED IDDistance to nearest: Well Foundation Property Line' AY r� SAN JOAQUIN C0UN�'Y SEEPAGE PITS I I Depth Size Number PikiBLIC IdE l N 3; �� 1��siI " �il�15i.1i�I SUMPS Ll Distance to nearest: Well Foundation ProprtY I e DISPOSAL PONDS ❑ 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."Contractor's 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 applica m st call for all required inspections. Complete drawing on reverse side. �} Signed X _ Title: .6eoeoG �� _ Date: `Z Z FOR DEPARTMENT USE ONLY Application Accepted by 4� Date .5 ! Area 3 Pit or Grout Inspection by 716lZ Date T �L Final Inspection by Date 7-FI-3 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 INFO AMOUNT DUE AMOUNT REMITTED. CK 9 CASH RECEIVE BY DATE PERMIT-NO. +-EH 13'24(REV. i n 5! EH 14-28 U o L r4 i