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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., S OCKTON, 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 app i made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 18f2 for well/pump and the Ryles and Regulations of the San Joa in Local Health District. _ t Job Address 11 r Q Sof 'S.�1J t , Ci L cd� Lot Size PM 5100 F j yy Owner's Name _KGwr O 01 �O• Address 172I E- }?1a :4. C h&14GLYI Phone I I Q T,N/ Contractor Address t��1 AYr► htzcense 1 No. Phone � TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEM NT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REP IR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mameca Dia. of Well E cavation 4►G Dia. of Well Casing Z 0" C Domestic/Private , C] Grave! Pack ❑ Tracy Type of Casing P VG Specifications. f W tic j D,tFjer 0 Delta Depth of Grou Seal Type of Grout 11Irrigatio 70Qpr pprox. Depth ❑ Eastern Surface Seal Installed by ` Repair Work Done El Type of Pump H.P. -State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Flier Material (Below 50' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ WAIRiADDMON ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feetJ 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 'Capaci No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: VM Foundation Property One LEACHING LINE ❑ No. &Length of lines —,Total length/size _ FILTER BED ❑ Distance to nearest: V" Foundation Property Line SEEPAGE PITS ❑ Depth Sae Number SUMPS ❑ Distance to nearest: VYe4 Foundation Property Line DISPOSAL PONDS ❑ I hereby.certify that i have prepared this application and chat the work wilt 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 fdkwing:"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 subjecttaworkumes compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance affie worts for which this permit is issued, I shalt employ persons subject to workman_'s compensa- tion laws of California." The applicant t call for all required ' ispec' C drawing on reverse side, (j Signed '7�'t' '� Title: Date: i S R D VA TME SE ONLY 77 Application Accepted b —._ --- Date �j �� Pit or Grout Inspe i n by iltit��!__�Final In pection by ..__ _. ..,` __ Date Additional Comment Stk 466-6781 ❑ Lodi 369.3621 ❑ Man&= OZI-7104 Q Trac 8355-6385 Applicant - Return all copies to: Environmental Health Paan6/Services 1601 E. Hazel t n Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT 0.UE AMOUNT RMTTED CASH RECEIVED BY DATE PERMIT NO- EH13-24144EV �. ! afll Tit J •_��—�� "i>9— { -30 5-l!14.26 ------ --'_-W r