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APPLICATION FOR PERMIT r g` SAN JOAQUIN LOCAL HEALTH DISTRICT ke Gd`el-o' 1601 E. HAZEL T ON AVE., STOCKTON, CA yo Telephone (209) 466-6781 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address _,Z � X 64-2T19aDL City ZTIG Lot Size 73 X I ro' pM Owner's Name Qr`15.9/0 &JA 2D Address Phone d—ex_n— Contractor 'L-0 VZ> 4le&1D Address 7 4J41 4v,14: License No.` 7yPhone b r 3 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION RICULTUR LL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mant ia. of Well Excavation pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ a c y Typ of Casing Specifications 1-1 Public f l Other ❑ Delta Depth o rout Seal Type of Grout — I I Irrigation _.Approx. th I ] Eastern Surface Sera) ailed by Repair Work Done ❑ Type of P p -H P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DE U TION 'I Wo eptic system permitted if public sewer is av able within 200 feet.) Installation will serve: Residence_e1*1 Commercial_ Other n Number of living units: A— Number of bedrooms Character of soil to a depth of 3 feet: Water table depth JJJ SEPTIC: TANK ❑ Type/Mfg -- Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 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 I Depth Size _ Number SUMPS W .el LI 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, and rules and regulations of the San Joaquin Local Health Di§trict. 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, 1 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 laves of California." • . .1 W The applicant must c IE for all required in tions. Complete drawing on/reverse —side. Signed X_ Title: L�rfif,[. Date: Q ` FOR D.EPARTMEAIT USE ONLY Application Accepted by Qa-�CA �a� psrix _ '1% Date �- Area Pit or Grout Inspection by Date Final Inspection by ` Date �Z j4 Additional Comments.- Ll omments:❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO tMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. EH 3-24� EH142B)REV.a/H5a 3O C�� f't �� I . r