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l� _ APPLICATION FOR PERMIT ' tP SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone) (209) 466-6789 i PERMIT EXPIRES 1 YEAR' FROM DATE ISSUED � � (Complete in Triplicate) 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 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'II ` Q S t� y City Lot Size PM `III yy�� IM � Owner's Name T/%1 Address r r r �/ Phone D2�i'd /c�;� �i r. Contractor �. ;�' �.Addresso�� 1fJ.L-.�d�i License No. 4 �J Phone TYPE OF WELL/PUMP: NEW WELL WELOREPLACEMENT D DESTRUCTION O PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES) ~~ DISPOSAL LD,rte" PAOP. LINE ,. FOUNDATION 1� AGRICULTURE WELL �� OTHER WEJL__ �~ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ IndustrialIL- !IIS ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ID, -_ Dial of Well Casing .Domestic/Private XGravel Pack ❑ Tracy Type of Casing Specifications L� Cl Public ��I n Other II Ll pelta Depth of Grout Seal rf� r Type of Grouter f2l.(IC I I Irrigation i c4 tApproxli Depth 1 I Eastern SrlHace Seal Installed by LLLIf /c!/��A)S1 Repair Work Done ❑ Type of Pum I ' I -- li ,p H.P. --- k� — State Work Done Well Destruction ❑ Well Diameter i' t Sealing Material Itop 50') 1 i ,IIl Depth IM Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION I I DESTRUCTION I I (Nolsepuc-system permitted if putiGc sewer is W available witfsin 200 feet.) Installation (will serve: Residence�1 Commercial _ Other Number of living units: Number of bedrooms dl '� i Character old soil to a depth of 3 feet:f Wateitable depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TfiE'��rTIVI NT-PE'T-PLI ' I Method of Disposal I� ( Distance to nearest: Well Foundation Property Line LEACHI G LIN _ In r' l i ` `❑"-Nomm&'LengthFof Slines Total IengtkJsize FILTER BED 1 ' ❑ Distance to nears tfWseli, tFoundatior � '' -Property Cine SEEPAGE�PliS'l 11 Depth LifL ze Number fSUMPS ❑ Distance �Foundatian . Property Line DISPOSAL PODS ❑ 1 hereby certify.that I have prepared this'application.� d that the work will be dori`A�m acC�r�ance withr'San Joaquin county ordinances, state laws, and rules and/regulations of the.San Joaquin Local Health Do-strict. 1 j Home owF i,ner d"J'licensed a-g nt's'sigri'iu `certifies the following: "I ce�that in the performance of the work for which this permit is issued, l shall not employ any person in such manner as"to,,become subject to workman's compensation laws of California "I Contractor's hiring or sub-contracting signature certifies the following: "I certify that�in-the perforirtance of the work for which this permit is issued, I shaft e tion lawslof CAlifornia. I p ploy persons subject to workman's compensa- tion The applicant�� r II r q' 'A i ion's: Complete drawing on rever a Aide. Signedi itis: ( ! ® U Date; t r`t FOR DEPARTMENT USE ONLY IIApplication Accepted by r..i Date Area Pit or Grout fnl pection by Date -V Final Inspection by Date Additional Comments: ❑ Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 II ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1661 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE NFO AMOUNT DUE '� AMOUNT REMITTED `ASH RECEIVED BY DAT FERMIT'NO. +.EH i 3t277 13-24II il� / `y� EH 14-28 ' ; 111 ,r _ r {{7�]/t