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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVL., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1"YEAR FROM DATE ISSUED SCANNED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora 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. 7 - - -------.__ Job Address City Lot Size PM � J/ �,JJ��ryry Owner's Name /tJ�/Y 1ZaN Address t hone D�tlft ��ma�y`` � Contractor /v!( 7N/S Address IW,2e lvl4ee9 License No. gf Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION l SYSTEM REPAIR El _ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK O SEWER LINES of DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �7 El Industrial ❑y�Open Bottom ❑-Manteca Dia. of Well Excavation Dia. of Well Casing C9 i Domestic/Private Avravel Pack ❑ Tracy- Type of Casing GGZ'-! Specifications fl Public .,❑�Ot er CI Delta Depth of Grout Seal �dL Type of Grout I I Irrigation e�'�`.Approx, Depth I I Eastern Surface Seal Installed by-_ l 547 f Repair Work Done ❑ Type of Pump H,P. Z_ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 - Depth Filler Material (Below 50'1 , ) TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo Septic system permitted if public sewer is r1" available within 200 feet.) installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity____________!. No. Compartments l PKG. TREATMENT PLT. ❑ '�- - 1 Method of Disposal ` Distance to nearest: Well Foundation Property Line i - rt.^1 _nom-�.-�• �. L �, -.. 'LEACHING LINE ❑ No. & Length-of.lines Total length/size FILTER BED ElDisiartice'to neat W;r ell" Foundation Property Line SEEPAGE PITS l I Depth 'Size _.` Number SUMPS t_) Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ U 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 not?7 employ any person in such manner as to become subject to workman's compensation laws of California."Coniraetor's hiring or sub-contracting signature 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." Tho applicant- squired " t- Complete drawing on rev a side. p, Signed X Title: - ' Date: �+ FOR DEPARTMENT USE OIKLY ., Application Accepted by __ _ Date U4 Area I � Pit or ro t Inspection by Date I Final Inspection by pate r1 Additional Comments: ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. \ �3 + EH 13-21(REV,ti ns) 06 IM. .� EH 14-28 lei <Db