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CD APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 1 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 wellipump and the Rules and Regulations of the San Joaquin Local Health District. Job Address V ffl 5z&5 e.n _ '^" City rI Lot Size l __. PM Owner's Name �!1.�1tl Address �SJ�U wtCzLS�y__lt/1�.... honpg��sr Sb&7 Contractor r� r'r �' ` ��/Ili D t:0 z Address S � Licens� No.- 0�n�-67r-�_ "~ - OF WELL/ PUMP DISTANCE TO NEAREST INTENDED USE ❑ Industrial ❑ Domestic/ Private h Public 1 1 Irrigation Repair Work Done 17 Well Destruction OF SEPTIC WORK -V NEW WELL ❑ WELL REPLACEMENT U-DESTRUCTION;D",i PUMP INSTALLATION ❑ SYSTEM REPAIR U OTHER ❑ SEPTIC TANK �_— SEWER LINES __._ DISPOSAL FLD. PROP.- LINE FOUNDATION �__ AGRICULTURE WELL OTHER WELL PITSISUMPS _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing LJ Gravel Pack ❑ Tracy Type of Casing Specifications n Other Cl Delta Depth of Grout Seal __ Type of Grout _Approx. Depth I I Eastern Surface Seal Installed by Type of Pump ________. H,P. State Work Done Well Diameter +_ Sealing Material (top 50.1 A 4Ut-- Depth d j %� +}IISf Filler Material 16alow 501 — NEW INSTALLATION Ia REPAIR/ADDITION I I DESTRUCTION I I (No septi: system permitted it public sewer is Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg .______._........-_ PKG. TREATMENT PLT. L within 200 feet.) 1. __ Water table depth Capacity No. Compartments! . Distance to nearest: Well _ _ Foundation LEACHING UNE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest. Well SEEPAGE PITS I I Depth Size SUMPS Ll Distance to nearest: Well DISPOSAL PONOS 171 Method of Disposal . Property Line Total length/size Foundation ___ Property Line Number Foundation Property Line 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, I shall employ persons subject to workman's compensa- tion laws rnia." The applicant us II 1 required inspections. Complete drawing on reverse side. r Signed X Title: Date: FO EPARTMENT USE ONLY Application Accepted by Date -&_;Z/ _ft=522�1 Area Pit or Grout Inspection by Date ._..._..�. Final Inspection by Date Additional Comments: J �" ❑ Stk 466-6781 D Lodi 369-3621 C1 Manteca 823 7104 L7 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 6 EH 13-24 {REV. 1/ 4, EH 14-29 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE ' PERMIT NO. INFO C SH �t a=) -Irks