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APPLICATION FOR PERMIT I ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601-E. HAZEL T ON AVE., STOCKTON, CA � Telephone (2091466-6781 , PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Lor.al 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. 11362 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ' Job Address City Lot Sue i �,2�^^^<.. Owner's Name +"�'a"A dr� - Phone ?0 ,i Contractor AMcE14S&22L5JcAddress11)J>A_&-0L4At" License No. lqlaolz Phone TYPE OF.WELLlPUMP: 1' NEW WELL ❑ WELL REPLACEMENT"❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ it DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DI LD. PROP. LINE FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS INTENDED USETYPE OF WELL PROBLEM A ONSTRUCTION SPECIFICATIONS `t ❑ Industrial ❑ Open Bottom 0 eca Dia. of Well Excavation Dia. of Well Casing' r), E ❑ Domestic)Private ❑ Gravel Pack , ❑ Tracy Type of Casing Specifications {f Fl PublicCl 0 Cl Delta Depth of Grout Seal Type of Grout I I loigation ' ' .Approx. Depth I I Eastern Surface Seal Installed by - Repair Wor ❑ -Type of Pump H.P. State Work Done bL Well estruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIRlADDITIDN pESTRUCTION (No septic system permitted if public sewer is q' available within 200 feet.) Installation will serve. Residence_ Commercial Other Number of living units: Number of bedrooms - + Character of soil to a depthiof 3 feet: Water table depth �j SEPTIC TANK- -Type/Mfg Capacity O No. Compartments i!' PKG. TREATMENT PLT. ❑. Ii Method of Disposal .IMDistance to nearest: Well Foundation Property Line i LEACHING LINE �No. & Length of lines 3 O �' Total length/size FIIRR BED ❑ j,Distance to nearest: Well Foundation Property Line SEEPAGE PITS I'Depth Size Number SUMPS ,: Cl i Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 11 I 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."Contractors hiring or sub-contracting signature l certifies the following: "I certimthat 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 ust call f all quired inspections. Complete drawing everse side. igned Title: Date: i FOR DEPARTMENT USE ONLY Application Accepted by . W Date 11� 1 Area PR or Grout Inspection by = r Date Final Inspection by.,49:491 Date 7 Additional'Camments: ❑ Stk '466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 93544 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 FEE INFOINFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. # _ 10 Eli 14-2e II - r.'+"T.%°rv^r: .' .r-.�F':'i�.:a�`i ... .,....,-:. ".- .-..:.,., 'ir—�. .:^¢; ....�;:`.'.r:'_ -?".."".._ .�'a'�f"''"-`-_"T`°-`":_- '•Y', "tet �!%� ,i':... ."T- -