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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 TYEAR FROM DATE ISSUED qi (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 4 made in compliance with San Joaquin County Ordinance No. S49 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address —L` 's A UPi/VUP� c!/ ; _- City Lot Size l PM r Owner's Name d tr Address 4:91 0 wok �fL�� – Phone 144 Contractor `°I: ��.. _1's_. ' Address " License No, Phone_ TYPE OF WELL/PUMP: ;,NEW WELL ❑ -WELL REPLACEMENT ❑ DESTRUCTIO t.y SYSTEM REPAIR ❑ OTHER out O�S�U1(C PUMP INSTALLATION ❑ 9` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ROP. LINE � . .FOUNDATION _ AGRICULTURE WELL OTHER WELL PiTSISUMPS INTENDED USE ;TYPE OF WELL PROSLEM AREA CONSTRUCTION SPECIFICATIONS ❑ 11 Industrial ❑ lJpeii M ttorrt „ Manteca Dia. of Well Excavation Dia. of Well Casing °-tri.. ❑ Domestic lPrivafe ❑ Gravel Pack - L3 Tracy i�^� <Type of Casing Specifications 1'1 Public I 1 Other iD Delta,; Depth of Grout.Seal Type of Grout I I ! Irrigation —..Approx. Depth I I Easternb�r— Surface Seal installed-by '11.p_ I Repair Work Done 13 Type of Pump State Work Done,_.. , ' Well Destruction O Well Diameter ' Sealing Material {top 501 Depth FillerMaterial (Below 501 `. TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIRIADDITION t I DESTRUCTION I I INo septiADi7sposal mitted if public sewer is I , available et.) Installation will serve: 'Residence— CommerciaF�--�Other�=- Number of living units: Number of bedrooms}�h - Character of soil to a depth of 3 feet: f "" 1 a Wath `SEPTIC TANK ❑ Type/Mfg "• Capacity Nonts PKG. TREATMENT PLT. ❑ ,� f MeosalDistance to nearest: Well Foundation �:Poperty LEACHING LINE ❑ No. & Length of_lines - f Total length/size f FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS •: C I Depth Size Number � ! SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that t 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 fallowing: "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 t call for I required ins ns. Complete drawing on reverse side. Signed X, /tet/ Title: Date: C FOR DEPARTMENT USE ONLY t Application Accepted by % -� �L,L "' � Date 'r( !-�— Area Pit or Grout Inspection b / Date Final Inspection by Date Additional Comment ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca {823-7104 #❑tTr cy 835-6385, Applicant - Return all copies to: Environmental Health'Permit/Services 1601 E.Hazelton Ave., P.O: Box 2009, Stk., CA 95201 4 ' FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO f + EN 13-21(REV.riNsr �j! EH 14-2e