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APPLICATION FOR PERMIT SAN JOAQUIN LOCALFHEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 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. i ra5� Ga.sQ. U ,S �GeQ.'. �_ Job Address I — - City I,�I__ Lot Size 'PM Owner's Name V-0-040 Q r - Address IZLI t• #141� �4.,C k +► 47AI Phone ki N.. t Contractor."141- 'I, ' aFAddress S Ar0dja4r4j7C"& License No. Phon 7�s Z7 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR.q," OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP-..LINE FOUNDATION AGRICULTURE WELL 0TH WWELL j'"" PIT_S/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIONtk'CIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavati n Dia. of Well Casing El Domestic/Private LJ Gravel Pck ❑ Tracy a Type of Casing'"""""p Specifications ' ,X%blie��0/7% hr ther— _ 11 Delta Depth of�Grout 'I —11y Type of Grout ❑ Irri ationS � I•......�.,....._.�_-,....�.._.-...._I .o.�.. �y g 0 pprox. Depth ❑ Eastern Surface $eallinstalled by r Repair Work Done ❑ Type of Pump H.P. r State Work Done t Well Destruction Ell Well Diameter, f � f Sealing-Material Wp 50'1 f . Depth ' Filler Material (Below 5b') I -�•—� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ I DESTRUCTION':El (No septic system permitted if public sewer is { available Ovithiri 200 feet.) b Installation will server Residence_ Commercial_ Other I Number of livingunit:""—Number-of"b"edrDvrtts--- Character of soto a depth of 3 feet: Watwr table depth SEPTIC TANK ❑ Type/Mfg r Capacity -° Not Compartments,,4 I 4 > ) f PKG. TREATMENT PLT. ❑ f• . ---, - c. f Method of Dis`bhA Distance to nearest: Well Foundation = Property,Line' -a I t h LEACHING LINE ❑ No. &iength,of lines ~```f Total length/size E FILTER BED ❑ Distance to nearest: Well Foundation Property Line•_.:r SEEPAGE PITS ❑ Depth, f Size Number ~ SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ _ I hereby certify that I have prepared-this appjication and ihat the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Hrealth District. Home owner or licensed agent's signature oertifies the following: "I certify that in the performance of the w6 k 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 certifies the following: "I certify th"et`in'the*1YePf6rmance of the work for which this pe4mit is issued,I shall employ persons subject to workman's compensa- tion laws of California." - -- I The applicant call for all required inspe 'ons. Complete drawing on reverse side. - Signed Title: �X4,eA Date: 3 �5 % FOR DEPARTMENT USE ONLY Application Accepted by r Date ' `� Are /J�� Pit or Grout Inspection by Date /� Final Inspection by Additional Comments: 44r �l " t. �/ -z'�"'�""- ❑ Stk 466-6781 ❑ Lodi 369-3621 anteca 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 RECEIVED BY DATETPMIT"N0. or + EH 13-24 iREV.7/051EH 1426 �-;7