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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1"YEAR FROM DATE ISSUED (Compiete.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. t Job Address ZS 1 y-a 0A City Lot Size_-L5- X `,SI PM ff z�� P-to &-a a.-- Iks Pctsl� . Owner's Name A�(D Pn CA, L6 `o• Address " �a� �G-'fro e R yD3 Phone 1-5 Contractor `'uAddress �. 7 L0 e�q3-r6 s �`�f6,�s g3 ♦wicense No. Phon TYPE OF WELL/PU P: 'Z., NEW WELL x'4,6WEL LACEMENT ❑ DESTRUCTION C3 PUMP INSTALLATION ❑ 1 EM REPAIR .❑ OTHER ❑ J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE �_Jly p! G►— FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavatiioo1n pia. of Well Casing ❑ Domestic/Private Gravel Pack T. Type of Casing t"v L Specifications F1 Public F1r Other n Delta Depth of Grout Seal s Type of Grout Ir itpati 3y_ Approx. Depth I I Eastern Surface Seal Installed by. ea�%�_ ee W it PJ YP P _ e air or bon ❑ Type of Pum H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 ! Depth Filler Material (Below 501 h TYPE OF SE IC WORK: NEW INSTALLATION I T REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is [ available within 200 feet.) s Installation will serve. esidence_ Commercial_ Other Number of living units: Number of bedrooms 9 Character of soil to a depth of 3 e Water table depth EPTIC TANK ❑ Type/Mfg Capacity No. Compartments $UKG. TREATMENT PLT. ❑ Method of Disposal xx Distance to nearest: Weil Foundation Property Line fit"• f -r EACHING LINE ❑ No. & Length of lines Total tength/size Z r ILTER BED ❑ Distance to nearest: Well - Foundation Property Line Z EEPAGE PITS 1 I Depth Size Number ' & UMPS L-1 Distance to nearest: Weil Foundation Property L C DISPOSAL PONOS ❑ -: % 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. 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 following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of liforni .The applica must for all r quir inspection . eta ing on reverse side. Signed heti Tide: + fS Date: �`� FOR DEPARTMENT USE ONLY C� z Application Accepted by Date I v Area f Pit or Grout Inspection by "�—l� _ _ Dat Zf Final Inspection by e"aw�"�_ Date z Additional Comments: Z Tic' _ ❑ Stk 466-6781 ❑ Lodi 369-WTj_ 9EMH DiPlS= 83 6385 1 Applicant- Return all copies to: Environmental Health_Per_mit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk.,"CA 95201 [ SPECIAL PFAMIT . :{ FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO . EM 13-24 IRE:V.1/n 51 �r EH 14-29