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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 3 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. r Job Address Q e City+�-� � Lot Size PMS Owner's Name f YfQ Address r'y' Z�z LIQ Phone -139-2) 9.1 v ff .�' r loa �QA� 100'-9� Phone t� —03 Contractor I��r� � l u1�IP Address Ad icense No. 3 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM SYSTEM REPAIR 171 OTHER EI� DISTANCE TO NEAREST: SEPTIC TANK �4 SEWER LINES IODt+- DISPOSAL FLO. PROP. LINE 3(Jr FOUNDATION 30 t AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / P ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I � Domestic/Private IW'Gravel Pack ❑ Tracy Type of Casing a Specifications V' M Public 1-1 Other Cl Delta Depth of Grout Seal f An Type of Grout _- I I Irrigation -Approx. Depth J I Eastern Surf ce Seal Installed by Repair Work Done ❑ Type of Pump 5ubi7H.P, i' /sZ State Work Dane Well Destruction ❑ Well Diameter Sealing Material(top 501 Depth Filler MaterialrlBelow 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION=lJ_DESTRUCTION I I (No septic system permitted it public sewer is ` �i available within 200 feet.) I installation will serve: Residence_ Commercial~ Ot�he Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: `Z Water table depth t SEPTIC TANK ❑ Type/Mfg Capacity^' No, Compartments r� PKG. TREATMENT PLT. ❑ "'�^�— _,. t Method of Disposal Distance to nearest:. Well Foundation s Property Line r f LE , I ACHING LINE ❑ No. & Length of lines ► I Total length/size I FILTER BED ❑ Distance to nearest: Well Y a @+ Foundation Property Line SEEPAGE PITS I I Depth $ize. ; Number taw SUMPS ❑ Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will'lie dorie.in accordance with Sari 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 subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following':-;"l certify that in the performance of the work for which this permit is issued,a shall employ persons subject to workman's compensa- tion laws of Ca_lifor r 4 t II The applica urYf st call.for all required inspec'o . Complete dr ing an reverse side. 4 ; Signed Title: ' Date: 1 f fC1 ffj 1 FOR DEPARTMENT USE ONLY71t oOC f Application Accepted by F Date Area PitGrou inspection b�yJ) i Date f 3a 1 3 Final Inspection b. . .`t Date Additional Comments:. C1 Stk 466-6781 11Lodi 36,94211 C1M nteca 823- 04 .❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services:1601 E. Hazelton AVe., P.d: Ax 2009, Stk., CA 95201 6,FEE AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY D E PERMIT`NO. a,EH 1324 IREV.s i x s) a EH 14-2a