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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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 y-32 1✓RSiS�/.f/GJ'1r1N J77PE�r` City_; �77itsr 0 Lot Size PM //// /,,�� Owner's Name A!12 0j ei eo j. Address Q Phone 1��L38- 3 Spe um Explat", 45x5 E. (-209)I 4-1a-1351 I Contractor TYPE OF WELL/PUMP: NEW WELL 9 W WELL REPLACEMENT © DESTRUCTION ❑ 1 i PUMP INSTALLATION 171 SYSTEM REPAIR ❑ OTHER ;13(,3 M,,r4-}o1-iyl UWJeII DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES &_4 DISPOSAL FLD.4VA PROP. LINE � �J '� I FOUNDATION -A60-- AGRICULTURE WELL AA— OTHER WELL- /Vl# - PITS/SUMPS 4� i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation z Dia. of Well Casing Cl Domestic/Private 20 Gravel Pack ❑ Tracy Type of Casing" O'Vr " Specifications 17 Public hAilllpiirilw ❑ Other 11 Delta Depth of Grout Seal If Type of Grout AydEo_ 9:2�n I I Irrigation Wtuf 65�..Approx. Depth I I Eastern Surface Seal installed by,Ae_. PsAV _ Repair Work Done ❑ Type of Pump H.H.P. State Work Done _ l Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material {Below 501 T F SEPTIC WORK; NEW INSTALLATION I] REPAIR/ADDITION 1.1 DESTRUCTION I I iNo s=depth lic sewer availai Installation will se Residence_ Commercial_ Other Number of living units: Number of ON 1 Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments N PKG. TREATMENT PLT. ❑ Method of Disposal 4 Distance to nearest: Well ation Property Line 1 i LEACHING LINE ❑ No. & Length of lines length/size FILTER BED ❑ Distance to aiisir st: Well Foundation Pro Line I r SEEPAGE PITS Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line D AL PONDS ❑ I hereby certify that I have prepared this application and that tfie 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 shalt not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's(tiring 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 laws of California." , The applicant must call for all required in ctions. Complete drawing on reverse side. Signed X Title:_bra 41--CL0&l1 Ir Date: DEPARTMENT USE ONLY ��rcv,.dwa�-e,r Te�hnalac�y la-a��8� FOR DEPART 77Cj� , Application Accepted by Date v 4 Area Pit or Grout Inspection by Date Final Inspection by Date f`' -97 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 "T 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 CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24{REV.)/8 5) L EH 14-26 i