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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT V 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED --- — (Cornplete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a Permit to made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 forcwell/dpump and the Rules and Regu/or install the woik herein lations pf the application J In ' Local Health District, - .- y Job Address �/f City [ Lot Siza d PM ' Owner's Name 7�4�/(/4 3�Ki�/L Address 2,223 �Q 7K Ly �f- ZC, . Phone D Contractor 1 ,/<. U,1(' Address7Y Y� . Jy/Gj t' /IP' �- .3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ License No. REP' CEMENT, ,- .,« PUMP INSTALLATION ❑ DESTRUCTION ❑ DISTANCE TO NEAREST: SEP .---- SYSTEM,REPAIR ❑ OTHER ❑ ANK SEWER,LINES �-•DISPOSAL FLD. PROP. UNE ' - r FOUNDATIO `AGRICULTURE WELL — OTHER WE ITS/SUMPS INTENDED USE TYPE OF WELL PRO AREA. CONSTRUC CIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca O Domestic/Private o Well Excavation_ Dia. of Well Casing ' O Gravel Pack ❑ T Tyf� sing r El Public ❑ Other ❑ Delta Specifications ❑ Irrigation r I Depth of Grout Type of Grout Puroxmp Depth ❑ Eastern Surface Seal Installed by Repair Work Done ype o} pump H P � oQ ' Weil Destr ❑ Well Diameter - State Work Done a1 Sealing Material (top 501) Depth Filler Material {Below 50'1 9/ TYPE OF SEPTIC WORK: NEW INST,A/LLATION ESTR REPAIR/ADDITION ❑ DUCTION ❑ Ilio septic system•permitted if public sewer is Commercial Other J Installation will serve: Residence v available within 200'feet.) r JJ `Number of living units: --/— Number of edroa Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg .�f-rL dvr nAo,ta"' ��,'''��r��^''' ��_ Water table depth \ i ' PKG. TREATMENT PLT. ❑ Capacity No. Compartments T- Method of 0' so Distance to nearest: Well/5-0 Foundations 99 Pro party line ' LEACHING LINE No. & Length of lines fD FILTER BED Total length/size � ❑ Distance to nearest: Well is-n , Foundation x-20 Li ' _ Property Lia '74 �L� ' SEEPAGE PITS ❑ Depth 'Bile • " '• Number SUMPS Distance to nearest: ,,,.Well Yom;O Foundation DISPOSAL PONDS ❑ ', � ,6�" Property Line > Q 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 rules and regulations of the San Joaquin Local Health District.f 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 foNowing:"I certify that in the performance of the work for which this ' tion laws of Celifomis." permit is issued; I shall employ persona subject to workman's compenea- i The applicant m t�c/�JI f/oJr {7,r�equiredy,' Pections. Co late drawing on reverse side. Signed x /�-. '/��(�✓p7., G1 Title: 'w tw., Date: FO _ . R ?-' R DEPARTMENT USE ONLY Application Accepted by `Z, - Date t / Aree10 0 C Pit or Grout Inspection Date \�1..� r �2- �� :Final Inspection by • �—1JJ-1 L^ Date t m� Additional Comments: •'' El Silk 4666_781 ❑ Lodl 369-3821 ❑ Man[eca 823-7104 ❑ Tract 8358385 Applicant-Return all copies to: Environmental Health Permit/Servirxrs 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT�NO. � EN 1324111W I/a sl �H 1428 .�..-,... l•''"-tti - , _. ._ ._ ._. ,✓