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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ,tt PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDl (Complete in Triplicate) ' Application is hefeby 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. it f i �� r fr Job Address �J t ,I" t - a%L�'/_ 4 City i Lot Size PM Owner's Name 91 .I•� g, i l 1-0',_7Address / ' / -� C 4 e. j � fi', hone Contractor 5 �. i Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSIALLAT ❑ SYSTEM P 1R ❑ 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 C7 Industrial pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Do sticIPrivate Gravel Pack ❑ Tracy Type of Casing Specifications F Public Other I Cl Delta Depth of Grout Seal Type of Grout I i Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H,P. State Work Done _ Well Destruction ❑ Well DiamdIer Sealing Material (top 501 h L # Depth k Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INS TALLATION REPAIR/ADDITION I I DESTRUCTION I I INo 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:I Water table depth SEPTIC TANK ❑ Type/Mfg Capacity A2=0No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distances to nearest: Well Foundation Property Line t LEACHING LINE � No. & Length of lines Total length/size FILTER BED ❑ Ristancelto nearest: Well Foundation Property Line SEEPAGE PITS Depth J S Size . _ Number _ _ SUMPS Ll Distance)to nearest: Well� Foundation Property Line 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 F rules and regulations of the San Joaquin Local Health Di§trict. 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: r G(ir Date: .r--, =RTMENT USE ONLY � Application Accepted by Date Area Pit or Grout Inspection b A � Pe Y ff, / 'I Date Final Inspection by a!// Data #j r Additional Comments: 1�� I�� z ci✓� i �IrC/ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 11 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1~� INEE - MOUNT DUET AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. + EH 13-21(REV.1/H51 EH 74-26 �CJCi GL'j. �p r J 111 f f`7 �1( O_I176. �I