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APPLICATION FOR PERMIT 'PAYMEN 3 j ° SAN JOAQUIN LOCAL HEALTH DISTRICT RECEN 1601 E. HAZEETON AVE., STOCKTON, CA JUN 2 '*+i` � Telephone (209) 466-6781 SAN JOAQL1lN COUNTY PERMIT EXPIRES 1'YEAR FROM DATE ISSUED PL}13LIC ;"{FpLTH-SNTiCES I (Complete in Triplicate) "-1,viRO NMI ENTALHEALIt-I p'I,'ISiG-" 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. Job Address f •-" �C tO 61 City � Lot Size 'TC � PM /41 _ l `� '� Owner's Namef]"►✓L Y { 3-GLI.t Address � 31 S. �� d+-i Q hone Contractor �llS Y+! �(K Address �� 4 �✓`� �r / �` License IVo�7 � P h o n 2—1 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATI0N ❑ SYSTE REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.w` POOP, LINE--! FOUNDATION AGRICULTURE WEL THER WELL '�`c PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ �i ❑ Industrial [I Open Bottom EI Manteca Dia. of Wel{ Excavation Dia. of Well Casing omestic/Private P<Gravel Pack ❑ Tracy Type of Casing G Specifications i'] Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50') : ' - d TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewe_r_isr-O�` available within 200 feet.) Installation will serve: Residence-___ Commercial— Other v 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 ; Distance to nearest: Well Foundation Property Line LEACHING; INE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number _..p 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 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-no't employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatur 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 in ctions. Complete drawing on reverse side. } Signed Xz/ r "VfLLTitle: t f3"cL��' '`'• Date: Fp DEPARTMENT USE ONLY Application Accepted by Date ( / Area Pit or Grout Inspection by Date L Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ M nteca 823- 104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 A, IFEE NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. ` �— , �7 *AA EH 13241REV.1i»5) ',/� ► ) t , c,a. 7f ,,,� �' n ^ h 4 EH to-29 f ! .J fLNJ/✓h to