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i 3' I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 d PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) „;:<•'}��CZ Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereinid`sefiThis 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 Job Address Qfl � CxiL _. City Lot Size PM i 1 Owner's Name L1f ct-c Address `�� Phone Contfacto t,t, 4y (/ 0 `� ,�` _eeL-�3�"`f" {'��6 -2- Address License No. .. , Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKf -SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing D<Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (-1 Public Cl Other 17,1 Delta Depth of Grout SealType of Grout i I Irrigation _Approx. Depth l I Eastern //� Surface Seal Installed by Repair Work Done 171 Type of Pump ~ --H.P.ZrS� State Work Done Well Destruction ❑ Well Diameter `-Sealing Material (top 50') n Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION f I (No septic system permitted if public sewer is available within 200 feet.l._ Installation will serve: Residence_ Commercial Other Number of living units: —Number of bedrooms - � Character of soil to a depth of 3 feet: '? Water table depth i SEPTIC TANK ❑ T e/Mf YP g Capacity No. Compartments 1� PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size -FILTER 9ED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PETS 1 1 Depth Site _ Number SUMPS Ll Distance to nearest: Well 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, and rules and regulations of the San Joaquin Local Health Diltrict. 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 verse side. Signed X_ _ -�� Title: Dater FOREPARTNIENT USE ONLY A pplication Accepted by ". a Date Area o Pit or Grout Inspection by Data Final Inspection by 1 Additional Comments: ' •A�. ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-71U4 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 400410 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'No. ..'H 14-24 IpEV,i/x 51 FN 14-28 1 '