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r r j APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA }.., Telephone 12091 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED 1 11 (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 +� CJ t Lot Size S f�CEL PM Owner's Name Address (3ox 4,:�5 6j7@qt)-)/1J. Phone �1�1 A Citi . Contractor �cn [ ress License No. �k(l Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR 11OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK Lam..__.___ SEWER LINES DISPOSAL FLD.L.2-5 PROP. LINE r� FOUNDATION AGRICULTURE WELL -OTHER WELL PITS/SUMPS 4-Z(O 'INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� r ❑ Industrial O Open Bottom LlManteca Dia. of Well Excavation Dia. of Well Casing 1 ►1 *'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 71 Public n Other I I ❑ Delta Depth of Grout Seal Type of Grout & -E 1 Irrigation _.-Approx#Depth I t Eastern Surface Seal Installed by Repair Work Done tk Type of Pump H.P. State Work Done W Well Destruction ❑ Well DiameN"rr Sealing Material )top 50'I a r Depth t� Filler Material Melow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted-it public sewer is Ir available within 200 feet.) Installation will serve: Residence—] Commercial—_Other d Number of living units: Number of bedrooms I .. y Character of soil to a depth of 3 feet: Water table depth , SEPTIC TANK ❑ Type/Mfgl Capacity . _ No. Compartments f PKG. TREATMENT PLT- ❑ { k Method of Disposal r Distance to nearest: Well ,d •Foundation Property.Line LEACHING LINE ❑ No. R Length of fines` _ -Total length/size r - � FILTER BED E3 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I i Depth Size �'` Number SUMPS ❑ Distance to nearest: Well . Foundation Property Line DISPOSAL PONDS ❑ r 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. _,01- ._ 1 ► 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 shalt 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 n} The applican u call for all re uire 'nspection . Complete dra ing on arse side. Signed X� •!��"r Title: - Date: IOR DEPARTMENT USE ONLY 1 ; Application Accepted by lR�f GtM _ _3kBeer-��— Date ~1 �- Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3M-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. 1 INFO r.EH13-244REV.S/H51 of �'t 3-� z . EH 7428