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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES #'YEAR FROM DATE ISSUED 3. (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 Joaquin Local Health District. I Job Address "?CPS,evrm:rg AJIF City Lot Size I P-if ZOE> - PM A CA r �' R� �� Address Phone t�6 �Owner's Name CP1 ` ��- 0: r t T t-1 � �/I46Conlraetor �TS F Ja MAddress �.r'7 -ZZ Z Licese No. ne -11 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ WIPMEM PUMP INSTALLATION�❑ SYSTEM REPAIR ❑ OTHER 04�` t�16 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ._,DISPOSAL FLD. PROF. INE FOUNDATION AGRICULTURE,, OTHER WELL— INTENDED r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casin �J � ❑ Industrial ❑ Open Bottom- 11 Manteca Dia. of Well Excavation g ❑ Domestic/Private ❑ Other Gravel Pack E5 Tracy _ Type of Casing— Specifications F1 Public C - Cl Delta Depth of Grout Seal Type,of G ut I I Irrigation =..Approx. Depth i I Eastern Surface Seal installed by— Repair y Repair Work Done ❑ Type of Pump H.P. State Work Done _ ' Well Destruction ❑ Well Diameter Sealing Material (top 50') + - Depth Filler Material (Below 501 fitted if public sewer is i TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADD1T10N l i DESTR 8{7tt F of P Installation will serve: Residence_ Commercial _-__ Other i Number of living units: Number of bedrooms r� Character of soil to a depth of 3 feet: (I!�;, 2 rtiCOble depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 171ENVIROMENTAIl6MEA *osal 4. . _ Distance to nearest: Well Foundation ` - 'FERMff45QWJiGE 4 - LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED' ❑e Distance to nearest: Weil Foundation Property Line k SEEPAGE PITS i I Depth Size Number rSUMPS Ll Distance to nearest: Well Foundation - Property Line DISPOSAL PONDS ❑ 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 i .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 appli nt us ca I for required inspections. Complete drawing on reverse side. Signed X w/"� N Title: Date: 7" r FOR DEPARTMENT USE ONLY j Application Accepted byF - Date Pit or Grout Inspection by Date '" .Final Inspection by �e / 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 =FEEAMOUNT REMITTED -RECEIVED BY DATE PERMIT N +.EH 13-24 IREV.t i H sl EH 14-29