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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE:TON AVE., STOCKTON, CA � J f Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED k (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. 17 Job Address A wen �e k��-C City r Lot Size i PM G 1ee/yg fig ( _ . y . . Owner's Name /� Address �� - � `�` Phone Contractor Address d License No c.� -Phone-5,2 •-TYPE-OF WEkL/PUMP:--� —xN W-WELL- WELL.REPLACEMENT DESTRUCTION-E] - PUMP INSTALLATION SYSTEM REPAIR El OTHER DISTANCE TO NEAREST: SEPTIC TANK .-!S-: SEWER LINES DISPOSAL FLO. PROP. LINE/A J FOUNDATION AGRICULTURE WELL OTHER WELL , PITS/SUMPS/7U INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing Domestic/PFS ate ❑ Gravel Pack [ITracy Type of Casing �� Specifications {TI Public ❑ Other Cl Delta Depth of Grout Seal Type-of ItI9fe_,4!_L C ' - I I Irrigation —.Approx. Depth I Eastern ,Surface Seal Installed by ' 4cilk C, - r} Repair Work bone ❑ Type of'Pump H.P. 75i -State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth - * Filler Material (Below 501 — 1� TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is -�. -*- available within 200 feet.) Installation will serve: -Residence—', Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth,of-3-feet:--=- ¢LL Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Meths of Disposal r G 1 4 Distance to nearest: Well`, f "Foundation. -.Property Line . LEACHING+LINE ❑ is No- & Length of lines ^ Total length/size FILTER'BED ❑ -Distance to nearest: Well-. t Foundation Property Line �] % SEEPAGE PITS � I D ptfi__ Size Number rf� M SUMPS ❑ Distance to nearest: Wel! Foundation Property Line \`� DISPOSAL PONDS Ll `CJ 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 Di§trict. 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 of California." The applicant mast call for all re uired,in pections. Complete drawing on reverse side. - 4 Signe Title: rr = - Date: TI LENT USE ONLY Application Accepted by - - T Date °�� a""� "" Area Pit �Gr. nspection b ��h^ Data � Final Inspection by`l >� 1 �� - Date Additional Comments: v ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. i INFO 4� +.EHt3-291REV.$/Rt I -� 3^ �!� f73 EH 14-2a o-73S