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i l jr1l� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E, HAZELTON AVE., STOCKTON, CA Telephone {209} 466-6781 i PERMIT EXPIRES 1'YEAR FROM DATE ISSUED i (Complete in Triplicate) y Application is hereby made to the San Joaquin'Local Health District fora permit to constru o in all the work herein described. This application is made in compliance,with San Joaquin County Ordinance No.549 for sewage or No. 1862 for a d the Rules and Regulations of the San Joaquin Local Health District. 1�Y J Jab Address � City Loi Size r PM 4 � ""' . SL Owner's Name Address Phone"r –12 , ", 4 _ r . Contractor r Address License N0.�u �y P3ton,: G ^a s! TYPE OF WELL/PUMP: NEW WELL .❑ WELL REPLACEMEN DESTRUCTION Cl PUMP INSTALLATION L7 SYSTENL AIR ❑ OTHER p A DISTANCE TO NEAREST: SEPTIC TANK SEWE LINES DISPOSAL FLD. PROP. LINE FOUNpAT10N AGRI U WRE WELL OTHER WELL - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEI14,KfJEA CONSTRUCTION SPECIFICATIONS i 0 Industrial 0 Open Bottom ElMahieca Dia. of Well Excavation pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack jaTracy Type of Casing Specifications it i f �i Public `r' Ia Other ; '� f l pelta Depth of Grout Seal Type of Grout ! __ I I Irrigation Approw. Depth I I Eastern Surface Seal Installed by—� Repair Work Done t I Type of Pump - Ii.P. Siate Work Dry!se Well Destruction 1-1 Well Diarrie_ter Sea Material trop 50'1 Depth 3 � Filter Material (Belo i `TYPE OF SEPTIC WORK:- NEW INSTA'l_LA ION I'fl REPAIR/ADDITION lJf DESTRUCTION [ I (No septic system permitted if public sewer is i available within 200 feet.) ;y Installation will serve: ,Residence Commercial Other 6 Number of living units: Number of bedrooms , Character of soil to a depth of 3 feet: _ der.table depth ;f ti� ,SEPTIC TANK- ❑ Type/Mfg Capacity No. Compartments :PKG. TREATMENT PLT. [_] Methud t Disposal I o d to Di stone,p to nearest. ell FOUrillon Properly Line IV 41 :LEACHING LINE ❑ No. & Length of lines X To al length/size ' ,C� FILTER BED ❑ Distance t n r W i / o, ea est: Well F undation Pro ert Line P Y 1� f �� SEEPAGE PITS I ! Depth -Size_ _ Number �j SUMPS LI Distance to nearest: Well Foundatio T� n —__ Property Line �� ! DISPOSAL PONDS L_� r, 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 y i %employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature I 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 applicantAust call for Ar;required infections. Complete drawing on reverse side. sk+ Signo d X Title: date: / G , FOR DEPARTMENT USE ONLY Application Accepted by ��. bate��rte_ Area 12 r b Final Inspection b Date or Grout Inspection -Additional Comments. A- ;rib %�5 r�^ / C�.r� /de r" t t!Y -1,0 0 Stk 466-6781 0 Lor i 369-3621 CfMantoca 823-7104 0 Tracy 835-6385 �```� ,� ' i Applicant - Return all copies to: Environnontal Health Pormit/Sovicos 1601 E. Hazelton Avo., P.O. Box 2009, Sik., CA 95201 FOAMOUNT DUE AMOUNT REMITTED Asti RECEIVED BY DATE PERMIT'NO: ..EH 13-24 IREV.I/H h! �-7 EH 14-28 1