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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA FTelephone 466-6781 PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED ILE COPY _ (Complete in Triplicate) Application is heteby 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District...y1 x-73 Job Address � �yJ " S. EscALoN -BrILL a City GrAtMW671OLot Size 8`0 4-G• PM Owner's Name �'7OS7EQ `_ E' _Address logo IPA S �' Phone L 1W 5�AJ c� 10 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTE REPAIR C1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER INES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICU TURE ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AAEANTRUCTION SPECEFICATIONS ❑ Industrial ❑ Open Bottom El Manteca Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracyf CasingSpecifications ["1 Public Cl Other ❑ Deltaof Grout Seat Type of Grout t I Irrigation _.Approx. Depth I I Easterna Seal Installed by - Repair Work Done ❑ Type of Pump P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Fillef Material (Below 501 I' TYPE OF SEPTIC WORK: NEW INSTALLATION KREPAIR/ADDITION 1 1 DESTRUCTION I 1 INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_*!� Commercial_ Other f /1 Number of living units: Number of bedrooms 3 f V J Character of soil to a depth of 3'feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Z 1 5 PKG. TREATMENT PLT. 171Method of Disposal L Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth 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, ant 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 applicant must call for all rein inspections. Complete drawing on reverse side. uired Signed X � Title: t�� Date: `��,� FO DEPARTMENT USE ONLY .� l 4 �� Application Accepted by - � Qirin/� Date Area Pit or Grout Inspection by Date Final Inspection by Date a Additional Comments: El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 37 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 9, FEE + OUNt DUE AMOUNT REMITTED RECEIVED BY DATE PE�RM�IT' N0. INFO y Eli 13-24IREV.1x5) O �? r 1 EH14-2d O !