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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA • Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is he,eby made to the oiquin 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 gff Cit Lot Size aZJrO — ,[�'7$ PM f Owner's Name Addres (�J,s f Lfs�� 6 1 - •� �•-r2�V Phone \ t ,' jr Contract Address tz License No.3z�s?�-Phone / TYPE OF WELL/PUMP: V NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t ) � PUMP INSTALLATION ❑ SYSTEM,REPAIR ❑ - OTHER 13 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SAL FLD. `PROP. LINE i FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS. t INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS O Industrial ❑ Open Bottom ❑ Mant Dia. of Well Excavation Dia. of Well Casing ❑ DamesticlPrivate L1 Gravel Pack racy Type of Casing Specifications 11 P rblic +I ❑ Other (1 Delta Depth of Grout Seal Type of Grout— _. q 11 Irrigation E- - _A x. Depth I I Eastern Surface Seal installed Repair Work Done 1-1Of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Material (top 50')' { Depth Filler Material (Below 501 TYPE a SEPTIC WORK: •NEW INSTALLATION I RrPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted if public sewer is ' \ available within 200 feet.) C Installation'will serve: Residence X_ Commercial— -Other Number of living units: Number of bedrooms ~ , Character of soil to a depth of 3 feet: � ^ Water table depth SEPTIC TANK' 1 Type/Mfg &go_—. i J Capacity J16 F6�I..Y. No. Compartments PKG. TREATMENT PLT. ❑ T Method of Disposal (7) Distance to nearest: Well BC Foundation rye Property°Line 2-6 LX LEACHING LINE No. & Length of lines Total length/size o FILTER BED ❑ Distance to nearest: Well_Inn i,f. Foundation .moo (J!77_ Property Line SO E SEEPAGE PITSr l Depth Sin -L �' In 7 Number � Y~ I SUMPS Oistance to nearest: Well Io0 L Foundation'— Property Line §Ar2 , DISPOSAL PONDS ❑ I hereby certify that 1 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 Delimit 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 l certifies the following: '9 certify that in the performance of the work for whith'thi6 permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." ' The applicant call for all res r d spections. Complete drawing on reverse side. G _ ' Signed X--� Title: Date: FOR DEPA TMENT USE ONLY -Applicatlo Accepted by G1>_j Date/—& Area Pit or o n by ate�Final Inspection by rDate - Additional Comments: • ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Retum all copies to: Environmental Health Permit/Services 1601 E. Hazahon Ave., P.O. Box 2009, Stk., CA 95201 FEE If NFO AMOUNT DUE AMO�/U�•NT1`REMITTED CASH RECEIVED BY 1 GATEPyERMIT'NfO�.'7 • EH 14]91PEV.i i n St EH 13 N L.'s. � 0 U V ` "O",� / O •_�5/ r �