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APPLICATIJN FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2('J) 466-6781 i PERMIT EXPIRES 1 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.199 for we[;/pump and the Rules end Regulations of the San Joaquin Local Health District. ZZD�p � Job Address CityLf h Lot Size PM owner's NameKvo"— Address CM0 — Contractor's Name ''L� ��U— License No. _?a l S L L Phone 7 Z�-311 q { TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT C; DESTRUCTION G PUMP INSTALLAT,,��IO..N,,��C SYSTEM REPAIR G OTHER C DISTANCE TO NEAREST: SEPTIC TANK - / SEWER LINES 400r+ DISPOSAL FL13./60t— PROP. LINE FOUNDATION _�/ AGRICULTURE WELL OTHFR WELL 7Z" PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p H D Industrial Open Bottom ❑ Manteca Dia.of Well Excavation. — Dia. of Well Casing _ •4jiZomestic/Private C1 Gravel Pack D Tracy Type of Casing 44ZJIPSpecifications ��• V,'ublic D Other D Delta Depth of Grout Seal _� Type of Grout G Irrigation —Approx. Depth D Eastern Surface Seal Installed by_ - Repair Work Done Type of Pump _ H.P.— _ State Work Done Well Destruction Well Diameter _ Sealing Material(top 50') Depth— Filler Mateiial(Below 50') _ 1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION �-- DESTRUCTION avails Attic cystthin m permi�ttted if public sewer is Installation will serve: Residence_ Commercial_ Other Number of living units: Mumber of bedrooms Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK I G Type/Mfg Caoacity No.Compartments PKG.TREATMENT PLT. Method of Disposal Distance to nearest: well Foundation — Property Line LEACHING LINE _ No. & Length of lines Total iengthrsize -- ` FILTER BFD U Distance to nearest: Well Foundation Property Line' — SEEPAGE PITS G Depth _Size___ Number SUMPS C Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C I hereby cert r- tliat I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulr,tions 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 issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature c�rtrfies thf follovving:"I certify that in the performance of the work for which this permit is issued,I shat;emp!oy persons subject to workman's compensa- tion Iswr of California." The applicant 41sAll for all required i ctlo to drawing on reverse side. Date Title: Signed ��- FOR DEPARTMENT USE ONLY Date_fL—`4 L�sz S Area—11 — App5cation Accapted by - e anal Inspection by _-- Date _ Pit or Grout Inspection by ---- —_ Additional Comments: — G Stk 466-6781 G Lodi 3W3621 Manteca 823.7104 Tract/ 8356385 Applicant• Return all copies to: Environmental Health 0ermn/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I Cx RECEIVED 9Y DATE PERMIT NO FEE AMOUNT DUE AMOUNT RFMITTED cAS.. INFO .EM 1324 tItEV.10,60 1 t` <•, t ' EM 1426