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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 Rules and Regulations of the San J uin Local Health District. Lo+oteel,, Job Address 3 a Aqs+ir7 City 011 Lot Size QI aCvs PM f7of bf' M 9- 8 9 Owner's Name ' I a - I P i >D M Q. Address 603 Wilma.. �I/� Phone Contractor �ej�T Address SafY1� License No. Phone a-inC. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth Filler Material (Below 501 0(I TYPE OF SEPTIC WORK: NEW INSTAL ION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is �! available within 200 feet.) UJ Installation will serve: Residence_ Commercial Other Number of living units:—I— Number of bedroomJs Character of soil to a depth of 3 feet: r1CL Water table depth SEPTIC TANK Type/Mfg r �— Capacity/�OO No. Compartments PKG. TREATMENT PLT. ❑ / Method of Disposal Distance to nearest: Well>50 Foundation Property Line �jbU LEACHING LINE >No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well r Foundation JL?r Property Line>/Co SEEPAGE PITS ❑ Depth Size Number SUMPSistan to nearest: Well Foundation Property Line DISPOSAL PONDS,.'] ❑ I hereby certify at I have prepay this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and rg6lations of the Sag a Joaquin Local Health District. Home o0er or licensed age s signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employany person in sucynanner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certif s the following:" certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tio laws of Californ .' Th applicant m call for all requireUgosootomplete avVing on reve side. Sig ills: �_� �� Date: FOR DEPARTMENT USE ONLY plication Accepted by Date — 9 —�eMa n K /. 'S �it-or-6Feus.Inspection by Date_L :7 Final In Lotion by "A� Date ,2 7-50 7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 >t<anteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Hea h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASHCK '/ REECCd1EIVED BY DATE PERMIT"N0. + EH 13-24(R EV.I/8 5) -/0,!1-0 4 Do�'3 613? 'J / �� —?—?7 EH 14.28 J