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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 ' �f (Complete in Triplicate) Application is hareby 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 Ryles and Regulations of the San Joaquin Local Health District. ' y. Job Address Cit Lot Size W :�_ — PM Owner's Name r._. ' �`'uL Address .:-I , � 5 �_- l C p� Phone- -' -- Contraetof ldd Q? '(Ygi ," CA -Address ! I a '4! ��! License No.3_2&aCL� Phone ` �U ZPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT ❑ DESTRUCTION ❑ =-tom PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ . OTHER ❑ DISTANCE TO NEAREST SEPTIC TANK _ SEWER LINES — DISPOSAL FLD._—_ PROP. LINE• FOUNDATION —AGRICULTURE WELL _— OTHER WELL_—_ _ PITS/SUMPS = INTENDED IUSE TYPE OF WELL PROBLEM AREA4---WSTRUCTION SPECIFICATIONS ❑ Industrial C] Open Bottom ❑ Manteca Dia. of�Well-Exca g1on-'.—_ Dia. of Well Casing 71 Domestic/,Private n Gravel Pack ❑ Tracy Type of Casing_ Specifications ❑ Public ❑ Other i-! Delta Depth of Grout Seal _ ` hype of Grout * Irrigation,? —Approx. Depth ❑ Eastern " �� Surface Seal Installed by_— Repair WU Done fl Type of Pump - — � H. P. —_ State Work Done Well Destruction J Well Diameter — ( Sealing Material (top 601 — --- Depth . I Filler Material (Below 50'1 ' - - TYPE OF SEPTIC WORK:, NEW INSTALLATION ❑ EPAIIt/ADDITION K DESTRUCTIO--��N-- U�� INo septic system permitted if public sewer is ) ��able within 200 feet.) i Installation will serve: Residence _ _ Commercial _ Other Number of -fling units::-Number.of lbe,drooms Character of soil to a depth of 3-febt'.'. 3� rr d +✓� —__ l —Water table depth - 7 I SEIC TANK / ❑ Typo/Mfg Capacity No. Compartments t i PKI). TREATMENT PLT. ❑ jQ!r; }! Method of, Disposal Distance to nearest: Well-`_73^,`,Foundation ...Property Line _ � I I LEACHING LINE ❑ No. & Length of lines _ �': Total length/size_..' — t FILTER BED y, (-1 Distance to nearest. Well _. _ Foundation _ Property Line _ 00 It —`— —... 1/ - -"L.r SEEPAGE PITS ffr Depth �SJ —Size _— I2�—.' Number — -- — SUMPS ?— ❑ Distance to nearest: Well -� �_— Foundation t% Property Line DISPOSAL PONDS K F. 1 hereby certify that !;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 o`rlicerised 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 pe�sbn I such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies the follo' ng:''•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 Ctilifornla — (•: The applicant. 11st call for 11 re wired inspections. Complete drawing on reverse side. �} ,} 4 _ Signed X__ <� Title: Y ' ' � -- --- Date: Sh �'A . (7 FOR D ARTMENT USE ONLY Application Accepted by _ _ Datev- Area _L_' .._—._ 'V Gor Grout Inspection b'�� — Date 1 ._ Final Inspection by T14Data Ltt—gyp`. (, Additional Comments. __ - ------ r 171 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 • EH 13.241REV. 1:'85 EH 14.26 FEEAMOUNT INFO DUE AMOUNT REMITTED CK 1i RECEIVED 6Y CASH DATE: PERMIT'NO, _