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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 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 Joaquin Local Health District. Job Address ,6-4+/f ge "ArM4n City Z hLot Size I M Owner's Name 4? t i Address �� M blit-e Phone 67-74 -69S7 Contractor Q IYI IAA1 Address Seed iPo� (J d� icense No. �t0 4�b�1 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1"D _ SEWER LINES 0l DISPOSAL FLD. PROP. LINE 'i_a{ FOUNDATION S-01 AGRICULTURE WELL OTHER WELL PITS/SUMPSl INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11-Domestic/Private .Gravel Pack C1 Tracy Type of Casing ie Specificationsii �,Q�p�� M Public 171 Other Ll Delta Depth of Grout Seal Type of Grout&lAH11_ 9, I i Irrigation = __Approx. Depth I I Eastern Surface Seal Installed by Repair Work D6ne ❑ Type of Pump SWb� H.P.'�`3 - State Work Done _ Well Destruction ❑ Well Diameter r -.-��— Sealing Material itop-'50') Depth t� �( Filler Material (Below W) TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION I l-'DESTRUCTION I I-INo Septic system permitted if public sewer is V i available within 200 feet.) Installation will serve: VResidence_ Commercial _ Other ! ! Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: * 47 4 S l Water table depth` SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t �.. f PKG. TREATMENT PLT. El { j -,ff Method of Disposal t Distance to nearest:. 'Well � '- Fd-un-dation Property Line 1 LEACHING LINE ❑ No. & Length of lines �- Tota( length/size P FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Number a SUMPS ❑ Distance to nearest: �7Welll ! .Foundation Property Line DISPOSAL PONDS ❑ c 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: "1 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 t¢-workman's compens6- tion laws of Ir nrM93 - { The appli6a st call for all required ' ctions! late draw' g on-rE a side. Signed X -7 7-1Z 7 e: Date: 1 ` Z —q Z x FO DEPARTMENT USE ONLY? J f a Application Accepted by Date Area O Pit o rout nspection-by ate —Finaf�nspectionby— Pit by Date R Additional Comments: ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 '❑ Tracy 835-6385 t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. I�N � ��SH { +.EH 13-24 IRM Find 7 «� Cr ::�:� l2r- z�E7114.2e r q ��Q c r, r Z