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APPLICATION FOR PERMIT SAN-JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 11-YEAR FROM DATE ISSUED Y` (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, TMs 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. y Job Address ` City 11001:�Y',;0 Lot Size � PM 1`118t- Owner's Name 1lo s : ,l:s Q Address IOU ry, .ai' `�`d�J�i 121' d m�� _ Phone y a.."%J Contractor Address t .lit ' a'.sEJ �l�cense No, � t.�i.FJ Phone+J.�.�7"� '"' <i; TYPE'OF WELL/PUMP: NEW WELL WELL REPLACEMENT [I,- DESTRUCTION ❑ . w PUMP INSTALLATION [ „' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ' S ---_T ".,1f.�yt{ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation # st# Dia.of Well Casing r4 L;IDomesticlPrivate f:I Gravel Pack ❑ Tracy Type of Casing . , '- U')1t";C,tSpecifications f I`l Public• I:1 Other n Delta Depth of Grout Seal r Type of Grout tt' i pprox..Depth I I Eastern Surface Seal Installed by _ 1 I Irri ation r„ A s^;`� `r r ^'s Repair Work Done ❑ Type of Pump H.P. State Work Done ' : - Well:Destruction 1iWell Diameter Sealing Material (top 50') Depth ' ;Filler Material 18elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION.[ I (No septic system permitted it public sewer is. avai6ble'within 200 feet.) installation will serve: Residence Commercial Other ` F 'Number of-Living units., Number of bedrooms ; E_ x Character of soil to a depth of 3 feet: Water table depth - ; SEPTIC TANK ❑ Type/Mfg Capacity ,___�r -,No.-Compartments :PKG. TREATMENT PLT ❑ Method of Dispo`saI-'- j l Distance to nearest: Well Foundation Property+Line'- 11 :` rl I<EACHING LINE ❑ Ao. & Length of lines Total length/size 1 FILTER BED ❑ 'Distance to nearest Well Foundation Property Line SEEPAGE PITS l 1 ,Depth Size Numb& SUMPS - Li IDistancetc;tnearest: Well Foundation Propen�r Line - pISPOSAL PONDS ❑ I hereby conify that,I have prepared this,application and that the work will be.dopa in accordance with $an,Joaquin county ordinances, state laws, anc, rules and regulations of the San Joaquin Local Health Diltrict.. Home owner or licensed agen't's signature certifies the following: "I certify that in the performance of the'work itor which this permit is issued, I shall not ; employ any person in such manner as to become subject to workm4n's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the perform nce of the work far which this permit is issued, I shall employ persons subject to workman's compensa-tion laws of Califo�rtia.." ..;... ._.:.w.�..v�._.. .. r. ,' .,.. .. :.. .. ._. ........ . .... -,., :.._.._.-..,f . I , The.applicant mustlFall for all requrrad.inspectians. Complete drawing on reverse side: r f Signed Tithe C Date: _1 y- F DEPARTMENT USE ONLY F good JL Application Accepted by atArea 4 � t 1 Pit or ro Inspection byDat.2'' FinAHTTs e i n by ,Date ff Ir Additional Comments - ' ❑ Stk 466-6781 ❑ Lodi 393621 ❑ Manteca 7104; { -❑ Tracy 835-638 —. C Applicant-'Return all copies to: Environmental Health Permit/Se�vtces ifili) E. Hazelton Ave., P.O. Box 2009, Srk.,'CA 95201FEE: AMOUNT DUE,1 A1I UNT REMITTED', L INFO ASH ,•: -'RECEIVED BY t , DATE i PERMIT'NO. it +.EH 13.24[REV.rix 5) CH 1,0-26