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,! APPLICATION-FOR PERMIT �i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 11 "Telephone {209) 466-6781 ! PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , AComplete inrTriplicatel 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. I Jab Address s� City_ :5-lep . Lot Size T PM Owner'sName�JC)�I✓� ` ![�12 Address �C77J �' w �7� Ctl✓��f } Phone Contractor 1 Address License No. . Phone TYPE OF WELL/PUMP: i' NEW WELL ❑ WELL REPLACEMENT LJ DESTRUCTION EJ PUMP INS ALL TION-❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. LINE I FOUNDATION AG URE WELL OTHE PITS/SUMPS. , INTENDED USE TYIPE OF WELL PROBLEM AREA CONS N SPECIFICATIONS DoD ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Exca n Dia- of Well Casing !— y ❑ Domestic/Private ❑ Gravel Pack cy Type of Casing Specifications IJ Public ❑ Other ❑ Delta - Depth of Grout Seal Type of Grout ❑ IrrigationI pprox. Depth 171 Eastern Surface Seal Installed by Repair Work D Type,of Pump H.P. State Work Done Well Destruction ❑ Well(Diameter Sealing Material (top 50') Depth Filler Material (Below 50') d TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is 1J J !i available within 200 feet.) 1 Installation will serve: Residence_ Commercial_ Other Number of.living units: Ii Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK ❑ TI ' YPe/Mf9 Capacity No. Compartments PKG. TREATMENT PLT. El of Disposal —Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length'of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation, j `Property Line 6-1 � �r 1 SEEPAGE PITS l--•'Depth i r Size Number SUMPS ❑ Distance to nearest: Well k Foundation r Property Line DISPOSAL PONDS ❑ �` } 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 Sari 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'slcompensa- tion laws of California." ii 7licant st call for all r quired ' pections. Complete drawing on reverse side. SignedX � Title: Date: hl-14I! FOR DEPARTMENT USE ONLY ion Accepted by Date Area Pit or Grout Inspection by - Date Final Inspection by Date q Additional Comments: 4nn ❑ Stk 466-6781 ❑ Lodi 349-3621'. ❑ Manteca 823-7104 r ❑ Tracy 8366-6385 Applicant- Return all copies to Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE IY INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY` DATE PERMIT'NO. f G9s+ fes} + EH1344 iREV.iiy 5, ,i ��C) �� 20 f rte•. L1 { �� r-�., ' 1 r, i EH 14-28 I