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/I LGIvC�o 14. TV IO/O J ON£ LEFrfhe 1:20 APPLICATION FOR PERMITel SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZELTON AVE., STOCKTON, CA Y Telephone 1209) 466-6781 PERMIT EXPIRES t'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 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. p `�, t1. Job Address/? O I W 2/ 6.41_j 4 r"z^ Cityl f � Lot Size AC- PM Owner's Namee" x a = L' (an Address J-�p -t"'k+ ) ,/ "'e-Q V Phone — 0 i'q fes, Contractor 1.J - i�. Address License Nol(o 2. 7� Phone TYPE OF WELL/PUMP: NEW WELL K WELL REPLACEMENT ® DESTRUCTION R PUMP INSTALLATION 5k , SYSTEM REPAIR El OTHER ❑ � DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES a 00 DISPOSAL FLD. - PROP. LINE Z Oo FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationO Dia. of Well Casing W,Domestic/Private K Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other Ll Delta Depth of Grout Seal Se y Type of Grout I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. a- State Work Done_ Well Destruction tA Well Diameter Sealing Material (top 501 Depth � 00 ' Filler Material f8elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) r Installation will serve: Residence_ Commercial_ Other Oct Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth_ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ 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, an 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 subcontracting 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 u�t cAall rall�r(�'qur/fin d inspections. Complete drawing on reverse side. Signed X_ ✓G' �ti` v l. �. !'Title: ✓ 3-9, _ Date: FOR DEPARTMENT USE ONLY Appliceti Accepted by ate �s+ Ar Pit enspection b Date F` �hspection by Date/ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ Tracy 835-6385 r -rose r Applicant - Return all copies to: Environrnpntal Floalth Permit/ ervi s 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INEN CASH ,n EH