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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i 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 I 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. f D / Job Address /0 _1//0 �O//i _�Uf City �}�Lot Size /o L• s PINI Owner's Name nwx ! I� /� Address'aae Phone TICS"5? N�� .,Ssr DC7 Q� �C� /�Cr?cl r License Na. � 136FySl11� Contracior �C�l G r�11 Address r Phone TYPE-OF WELL/PU.MP:. NEW WELL LlWELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION IIT' SYSTEM REPAIR 171OTHER ❑ E DISTANCE TO-NEA_RESTr'SEP71C TANK SEWER LINES DISPOSAL FLD. PROP. LINE-.If . FOUNDATION AGRICULTURE WELL � OTHER WELL�- PITS/SU1IAp�S__ MITENDED.USE. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial LTOpen Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing (_ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public 17 Other ❑ Delta Depth of Grout Seal Grout _ I I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by_ Efff W Repair Work Done ❑ Type of Pum P YP P H.P. State Wor Well Destruction ❑ Well Diameter Sealing Material {top 501 i Depth iller Material (Below 501 O _ TXP_E_OF_SEPTIC WORK: NEW INSTALLATION I REP ADDITION DESTRUCTION I 1 Ircv�CJ ' j W 1 T public sewer is Installation will serve: Residence Commercial Other ti, Number t ENVIRONhIENT Al . E,L IV1�,04s— o living units: � Number of bedrooms .�R _ Character uf'soil to a depth-of-3-feet:-° - f7 /✓ _ Water table_depth— -Q j SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments .� PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE X No. & Lengthof lines y Total length/size FILTER BED ❑ Distance to nearest: Well c`�� Foundation -�_� Property Line L . SEEPAGE PITS I 1 Depth ____Size�4_.r^ f�_ Number SUMPS �<' Distance to nearest: Well _ LO)_ Foundation ��.,_ Property Line DISPOSAL.-PONDS ❑ - 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, ander rules and regulations of the San Joaquin Local Health Dliltrict. 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's compensa- tion laws of California The applicant must call for all required inspections. Complete drawing on reverse side. Q SignedX YL Title: - a Date: G �, FOR DEPARTMENT-USE ONLY Applicai Accepted by� Date �:�� Area /1Z1 P' rou Ins tion by ate ��-Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 .,."—.Q Tracy 835-6385 -k Applicant- Return all copies to: Environmental Health Permit/Services 160.1 E.tHazelto_n Ave., P.O�~Bo'x 2009, Sk, CA goof FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y? - l J INFO CASH -� DATE -» .. PERMIT•NOS t-EH 13-21IREV.1/K51 �� EH 14_28