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no APPLICATION FOR PERMIT 1 �1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone.{209} .466.6781 , PERMIT EXPIRES i 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 'If"i (�Q j� L^ City 4 a d Lot Size 1�C pM ,� r Flcr Owner's Name NC �'' - Address 0 7. Phone ContractAb_OdS I ,Qljlj AddressJE9 NI' QIf1Q 44 se No . "".Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION 1 SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK T-5, SEWER LINES _ ._ DISPOSAL FLD. 35' PROP. LINE FOUNDATION Sb _ AGRICULTURE WELL S�O OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial •' Open Bottom ❑ Manteca Dia: of Weli Excavation Lr Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing y g7 Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal " �.�® _ Type of Grout LJ Irrigation 4�L�pprox. Depth El Eastern Surface Seal Installed by Repair Work pone ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 "t J ^# TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ fNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other W Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 1RRRE LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation property Line DISPOSAL PONDS ❑ 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 of California." The applicant m st c I or all r uirad ins ctions. Complete drawing on reverse side. Signed Title: 712A 1J1_(3o11__ Date: 3 �fQF�DEPARTMENT USE QNLYApplication Accepted bypate—- f "-"1 ' " � Area ZP Pit or rbu nspection by pate�� G Final Inspection b Date Additional Comments: ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. SH 1 + EH 13-24(AEV.t/65) 0,K_1 � EH 14-28