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APPLICATION FOR PERMIT =9 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 , PERMIT EXPIRES 4'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 _`7`# A14-�/�`1W,-,_7Z1AJ City � � Lot Size PM Owner's Name `7r�J7iJA-S AV"7-D Address Phone Contractor_FL 0`' �� V--0Z> Address 7-X, .6AE",—_ .r License No.'i�1�]�G Phone TYPE OF WELL/PUMP: .• NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ?PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE ` FOUNDATION AGRICULTUR L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A. CONSTRUCTION SPECIFICATIONS PF v❑ Industrial ❑ Oa ca Dia. of Well Excavation `Dia. of Well Casing ❑ Domestic/Private ❑ Gracy Type of Casing Specifications V f"] Public ❑ ODelta Depth of Grout Seal Type of GroutI I Irrigation _. Eastern Surface Seal Installed by Repair Work Done ❑ TypeH.P. State Work DoneWell Destruction ❑ WellSealing Material (top 501 ' Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION l I DESTRUCTIO l INo septic system permitted if public sewer is d available within 200 feet.) i Installation will serve: Residence Commercial— Other Q Number of living units: Number sof bedrooms t Character of soil to a depth of 3 feet: Water table depth y\ 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 r- Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS {_1 Distance to nearest: Well Foundation Property Line 4 DISPOSAL PONDS 0 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,performanee 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 subcontracting 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 laws of Califor,aJa." The applicant must call for all required inspections. Complete drawing on reverse side. !! Signed X t Title: 9 Date: DEPARTMENT USE ONLY Application Accepted by Q9L__4_eWDate f � Area Pit or Grout Inspection by Dater Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Man eca 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. ♦ EH 1324 ME EH 14-28 V.€in5Y `•1�� u V I�- Pc` �•/ I