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x APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT L ` 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781O ✓DA� Cs +,C, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 2�0,S,gQG��• v (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 descr �+ ,p(Ii-tion is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulatio c} Joaquin 4 Local Health District. l,rS Brod V 3 Lot Size P Job A ress �^ � City M � 0.00e,%"5 v iO�� / Owner's Name /`i7 LSC/�l �Q� --- Address >�E. 2/�1 At f- �}fdT 122Lk J -_ _ Phone Contractor 6 Address c License No. 214 ' 3 Phone I TYPE OF WELL/PUMP: a NEW WELL Di WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK AQ6/ SEWER LINES DISPOSAL FILE).AM.'t PROP. LINE FOUNDATION. AGRICULTURE WELL.- OTHER WELL__t�2�_PITS/SU.MPS__�, _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing . X Domestic/Private Gravel Pack ❑ Tracy Type of Casing 0'0 Specifications / F l'1 Public F f Other ❑ Delta Depth of Grout Seal 1��< J-Type of ut �_+;�P� I I Irrigation _Approx. Depth t I Eastern Surface Seal Installed by GG�C G Repair Work Done ❑ Type of Pump H.P. State Work Done_ f Well Destfuction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') —_ TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION 1 1 DESTRUCTIONI,I 1 (No septic system permitted if public sewer is Q' f lr 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number • SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSA'L'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 Di§trict. 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." 4 The applicant must all for all required ins tions. Comp at drawing on r e side. Signed X le: Date: 9 I IF DEPARTM NT USE ONLY 7�' Application Accepted by Data ;rl—^'✓--f/ Area 2 Pit or Grout Inspection by ate Final)nspection by f Date Additional Comments: �/11 97 N U El5tk 466-6781 C3 Lodi 369-3621 ❑ Mentec 8217104 ❑ Tracy 835-6385 I<lry�3 ` Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., C 01 �`�` FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH ty +.EH1324 IREv.riK 5) tj !/drL/ �'� EH 10-2e