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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HE LTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA -04)041, Telephone (209) -6781CI N] PERMIT EXPIRES )'YEAR FR M DATE ISSUED F SAN �9 MAR U (Complete in Triplicate) (30�4 991 NI�IRo �C f/�rA 0r11 C Application is hereby made to the San Joaquin Local Health District for a permit to onslruct and/or install the work rae8 hoication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 862 for well/pump and the Rules and Reg 'fat Joaquin Local Health District. Job Address fly L and t Lot Size 163 X rr'' VA1M(7Ur r� Owner's Name —v_� .Li/1L.. Address � 2� � Phone 2–a4 582 0Z41 Contractor 4S{ R a Address 3233 License No!`57 554q hone« 639 727 TYPE OF WELL/PUMP: NEW WELL ❑ WELI41fPLAPE ENT ❑ DESTRUCTIONS PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 0 Industrial ❑ Open Bottom ❑-lvlanteca pia. of Well,Excaviition Dia. of Well Casing " ❑ Domestic/Private JK Gravel Pack ❑ Tracy Type of Casing Specifications Public n Other §<Delta Depth of Grout Sea! Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work pone ❑ Type of Pump H.P. State Work Done_ u Well Destruction ❑ Wel! Diameter- � Sealing Material Itop 501 . Depth ^! r Filler Material IRelow RO MIN TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I ! DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) In-stallation 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 O Type/Mfg Capa-ity No. Compartments jt PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundatio Property Line I k SEEPAGE PITS i I Depth Size Number 1 SUMPS Ll Distance to nearest: Well Foundatio Property Line . DISPOSAL PONDS Ll .1 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 Diltrict- 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 compensatio.r 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 per mit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant�muust call for all required inspections. Complete drawing on reverse side,' } Signed X�i� – � �1M"� Title: 'r?� `lI r�"� fjalfib: �j ` 14` F FOR DEPARTMENT USE ONLY Application Accepted by /� � �``�/"� Data [I(��y 4� Area _ Pit or Grout Inspection by �'- a"� Date r1/1 7" Rf IF Final Inspection by r�«'"`R�� > Data -2hl, i Additional Comments: � ] ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tray 5-6385 Applicant Return all copies to: Environmental"Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY J DATE PERM17"NO. EH 13-24 lAEV.tEH 14 26 .r