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APPLICATION FOR PERMIT VV� ' SAN JOAQUIN LOCAL HEALTH DISTRICT .a 1601 E. HAZE T ON AVE., STOCKTON,,CA fJyh� Telephone 1209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E r� iComplete 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- k Local Health District. i L - rr i Job Address 736 l� A( - �d+'✓sa Rd City Lock gp Lot Size Jram� PM F�I 03 �- Owner's Name 1Den.n f'J'.5V n C�i Address -MCIS-`I S- N TUILYy Rod Y Phone C.oniractor Z GAO-as 4-Sons Address 72 %_SrtnSr_T I3*- 6A47- License No.s539 0 y Phone r TYPE OF WELL/PUMP:; NEW WELL v. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION gr SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANK IO©f 4_ SEWER LINES DISPOSAL FLD. PROP-LINE s `' i a FOUNDATION! AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V ❑ Industrial OP6pen Sottom ❑ Manteca Dia- of-Well Excavation SI Dia. of Well Casing , P' CWDomestic/Private ❑ Gravel Pack, 40 Tracy Type of Casing .S% Specifications (� �. f M Public ❑ Other D Delta Depth of Grout Seal 5d Type of Grout��. 13 Irrigation 19 4 -Approx. Depth I I Eastern Surface Seal Installed by' Repair Work Done ❑ Type of Pump H.P.. State Work-Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION l 1 (No septic system permitted if public sewer is '^ -Residence— available within 200 feet.) t installation will serve: Residence_ Commercial Other Number of living Number of bedrooms Character of soil to a depth o Water depth !I SEPTIC TANK ❑ Type/Mig Capacity o. Compartments E A PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foun Property.Line II LEACHING LINE ❑ No. & Length of lines Total length/size 4' FILTER BED ❑ Distance It est: Well Foundation Property Line 1 SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISP SAL PONDS ❑ 4 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 Di%trict. 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 Per �op in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the foil=-ng-''1 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 Ctelifornia." The applicant must call for all required in pections. Complete drawing on reverse side. I Signed X__ od �{�r/J L _ Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or ou Inspection by Date Z�_ — Final Inspection by Date # r Additional Comments: A14LC) ❑ Stk 466-6781Lodi 369-3621 El Manteca 823-7104 L1 Tracy 835-6385 -9- Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 G S FEE AMOUNT DUE AMOUNT.REMITTED K RECEIVED BY DATE PERMIT-NO. INFO 4_.... C 13.24(REV.1iH51 T Q a4 o EH,4.28 1�S 1 ,c7 a �- -� -1 19/ � � !-;L Li *t