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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE,, STOCKTON, CA Telephone (209) 466-6781 J r I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) � 47C �* 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. Ir t f '42-7, 5 , 91AI KC E �s�r,,/ x�2 r Job Address City �r Lot Size _ PM � F t Owner's Name Al G f J s T l7 dJ�_rQkis�e, IC710 Address License No. Rhone_ TYPE OF WELL/PUMP: NEW WELL ❑^ f WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC T K. SEWER LINES DI AL FLD. PROP, LINE FOUNDATIO ¢ AGRICULTURE WELT. OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELT PROBLEM AREA CON CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ acy I Type of Casing Specifications Fl Public Cl Other ❑ Depth of Grout Seal Type of Grout a I ) Irrigation __Approx. Dept I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pum H.P. State Work pone Welif Destruction ❑ Well Diameter Sealing erial (top 50'1 t r y Depth Filler Material slow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 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 �J FILTER BED ❑ Distance to nearest: Well Foundation Property Line s i SEEPAGE PITS I I Depth Size _ Number w� SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be lone 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 of employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hi ring or sub-contracting signature certifies the following: "I certify that in the perfor ce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of 'for The applic nt t call squired inspectio . Complete drawing on reverse side. —^ Signed (� F Title: CE +� f`�L2/`�� Date: M r ' r l CC�� FOR DEPARTMENT USE ONLY Application Accepted by Date Area - z Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca B23-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE INFO ` AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. , r +.EH 13-24 I REV.t i it 51 m, V V sC ,'+ + EH 14-26 - $Q I