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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 1 YEAR FROM DATE ISSUED (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 Ryles and Regulations of the San Joaquin Local Health District. Job Address ��ICity J�i /C�G/� Lott S Size PM Q ? Owner's Name / 4 Gf��— S/�G�Address Vf/v�E Phone 02 z Contractor /L1DDiPl?�X�it/S j4/o1Wdd essZ/".Z/7 14ZJ1,(,_-4 a icense No.__V2WPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Ag SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 000 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications ❑ Public El Other ❑ Delta DepthofGrout Seal Type of Grout ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump_S �Ua_S H.P. IYZ,-* 3 State Work Done PLLL 7�UR / tom '04VAj Well Destruction ❑ Well Diameter Sealing_M%erial (top 501 4-l9,lSj�L L AJEll�$tj E�QS Depth Filler Material:(Below 501 1 Llt�7 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR.PADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is *'- available within 200 feet.) Installation will serve: Residence_ Cdimmercial "Other 1 Number of living units: Number ofdbedrooms. 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 (/I Q LEACHING LINE ❑ 'No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number J SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 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 mu cal for all required inspections. Complete drawing on reverses e. Signed X �,!s��yi�i.,G�3 Title: ! � -f Date: Z� g S� FOR DEPARTMENT USE ONLY Application Accepted by Date�/_ Area /� Q Pit or Grout Inspection by Date Final Inspection by Date '`-1 u 5_ 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 CK RECEIVED BY ` DATE PERMIT`NO. + EH13-24(REV.1/85) 1SLI EH 1426 I.