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06 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED I (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 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. Ir'c��,�+• ,� ��.Jy4L �� ? -,,;,, fr Job Address 40 l� r 1 1 �I IVLLuQ GAS, j �. City Lot Size C'r�v% PM Owner's Name 6 L'r Gt I [ Address Phoni(�13)7 I Contractor /J L(N,Y! 6�"ddress Z S� e Al License No. S�u�g Phan. `l�as=87rZ TYPE OF WELL/PUMP: II� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ •• ..OTHER -❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Le ❑Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑;Gravel Pack ❑ Tracy Type of Casing � - �D*41,1 C— Specifications M Public µr Ozther Ll Delta Depth of Grout Seal „ Type of Grout � II II Ir�riga 1 n�. Gee .�_Approx. Depth I 1 Eastern Surface Seal Installed b #14I Repair Work Ddne ❑ Type of Pump H,P. State Work Done T p Well Destruction W`ll Diameter ` Sealing Material ftop 50'1 Depth-�_ Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I 1 DESTRUCTION I 1 (No septic system permitted if public sewer is 4 I available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: �I Number of bedrooms Character of soil to a depthlof 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT ALT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line y LEACHING LINE ❑ No. & Length of lines Tata) length/size h- FILTER BED ❑ 'Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPSi ❑ Distance to nearest: Well Foundation DISPOSAL PONDS Property Line C1 :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 District. Home owner or licensed agents 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 certif 6 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 appli nt ust call for all r quire ins cti s. Complete drawing on reverse side. a Signed Title: O 8 Date: I R DEPARTMENT USE ONLY Application Accepted by a" C ^ s Date ��/�� a Area Pit or Grout Inspection by Ii Date Final Inspection by Date / Additional Comments: 0 1II ❑ Stk 466-6781 ❑ Lodi! 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .r C.Sa -6� 441 . I o—i ro T4"Lx �Y e i � � dr� IlPc� t•4iWi`E.� EE 1+"e, AMOUNT DUE AMOUNT fl ITTED INFO :r CA RECEIVED BY DATE PERMITNO. +.EH 14-24 I REV.I/x 51 EH 1028 �' � •` l��)�� 0