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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 1 Telephone (209) 466-6781 -, so 1. rf PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) - niiB 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 welt/pump and the Rules and Regulations of the San Joaquin Local Health District.. Job Address r City of Size PM Owner's Name � � A�94craaa 2 33 s� /1/ �0 �Phonne 6 X0'120 7 Contractor's Name `I' "cense No. Ph TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ y 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 ❑ Industrial ❑ Open Bottom --+O.Menteca— bia�'a1`IVen'Excavation Dia. of Well Casing. C1Domestic/Private ❑ Gravel Pack ElTraey Type of coming Specifications Type of Grout ❑ Public ❑ Otherr�y_ ` ❑❑ tN_�� Depth`.ot Grout Seel Ly ❑ Irrigation �pprox. - epth ❑ EMern �Sgr a"sl Installed by ' `� Repair Work Done ❑ Type of Pump —W H.P. y, State Work Done " Well Destruction O Well Diameter 1 Sealing Materiel (top 50') ` 0 Depth "� Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 'DESTRUCTION O (No septic system Perm"If public sewer is 1 available within 200 feet.) Installation will serve: Residencei Co}nmerGiiher 4 F Number of living units:—i Number ol.bedrooms aa-�- 1 Water table depth Character of soil to a depth of 3 feat: `� � �z— A SEPTIC TANK p.—Type/Mfg I' capaoityy.. .Gacr_.�!rAo. Compartments PKG. TREATMENT PLT.❑ .. 1 . ,` 1 — k /" V Method of Disposal FoundationProperty G i " � DiatarTrs to rest:�""'1Ne11 � Property Line OO — - T1_ -EACHING LINE M No. &Length of lines ^� '� iTotttaeel length/size6�- FILTER BED 2r�bata'nce to neatest: Well, L Y� FoundeYa3It N�'8, ,Propert/Line�[!i I y SEEPAGE PITS 4!r-,Depth as—J Size Number �— SUMPS ❑ Distance to nearest: Well Foundation r Property Line DISPOSAL PONDS ❑ 1 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 permit Is issued, I shall not employ any person in such manner as to become subject to workman's compensation sews 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 applicantplu�st call fore IIuired inspection Complete drawing on reverse side. Signed KP � / + Title: �� wl. wlT Date: 7 �� FO DEPARTMENT USE ONL 4N 1. 4 pate '� ' Area Application Accepted by yrs _ i I.In action by Date Pi - r Grout Inspection by ate Fina sp Additional Comments: r _ ❑ Stk 4666781 ❑ Lodi 369.3621 ❑ Manteca 873.7104 ❑Tracy 835-830 Applicant- Return alt copies to: Environmental Health Permh/Services 1601 E. Hazelton Ave., P.O. Bio 2000, Stk., CA 9501 FEE AMOUNT DUE g AMOUNT REMITTED DASH RECEIVED BY DATE PERMIT NO.- INFO . EM 1121IRIN 10111