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II � I � 0 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT h 1601 E. HAZEL T ON AVE., STOCKTON, CA ` Telephone (209) 466-6781 I; PERMIT EXPIRES 1 YEAR FROM DATE ISSUED,, Y -(Complete in Triplicate) - N�. i, 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.' Job Addressx. ) C, 14 Lot SizeX-34 • P, PM - ' Owner's Name XMr>LC L,-,s Address ri S� T=�N\ ,a—, Phone Contractor k"- r-.P Address-1SC]3 Nf4 71 p LicenseNo QZ_. 9 Phone OG TYPE:OF WELL/PUMP: .I NEW WELL ❑ WELL REPLACEMENT L1DESTRUCTION 171 PUMP INSTALLATION)< SYSTEM REPAIR ❑ OTHER ❑ .` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ;:M , ) INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATIONS y ❑ Industrial 1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L1 Domestic/Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications El Public CI Other �� El Delta Depth of Grout Seal Type of Grout ` Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of'Pun H.P. r. State Work Done Well Destruction' ❑ Well Diameter 1-22 Sealing Material (top 501 1=11< C Asp tJC� Depth I! !F n > Filler Material (Below-501' f S A rv� TYPE:OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ; a I available within 200 feet.) Installation will'serve: Residence Commercial_ Other k ' 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. ❑ li Method of Disposal Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. & Length of lines Total length/size- -� FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth I` Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS _ ❑ I herby 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 sdbject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following- "I certify that iri 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. i Signed X �--rt+a�Y:� Title: 1�.w.. Q �tJ Li Date: hFOR DEPARTMENT USE ONLY Application Accepted by �iL-1't3�s� Date 7�0`&"' Area it r� i Pit orGroutInspection by Date Final Inspection by � Dated a Additional Comments: 11' I ❑ Stk 466-6781 18[Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6305 .Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMrrII,TTED C SH RECEIVED BY DATE (PPE/R�MIT`'N/O.. + EH18-24iREV.1/s5) EH 1428 I