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f s APPLICATION FOR PERMIT SAN JOAQUI'N LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone (209) 466-6781 r„ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k t (Complete.in Triplicate) Application is hereby made to the San Joaquin'Local HealthDistrict for a permit to construct an install the work herein described. TMs application is Local Health District. E made compliance with San Joaquin County Ordinance No.549 for sewage or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin t '.n y Job Address MAS 7CGs}- City Lot Size PM Owner's Name Ml=k0S PrCnvrrZTj s Address r3 0 X G}i2./is/pA C Phone Z� 8Z3-&W? Contractor's Name IVOACIC 1-:10 A, License No. ��>< TYPE OF WELL /PUMP: NEW WELL ❑ Phone WELL REPLACEMENT ❑ DESTRUCTION ❑ 'PUMP INSTALLATION ❑ SYSTEM REPAIR I-` DISTANCE TO NEAREST: SEPTIC TANK OTHER,E3 - SEWER LINES — DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Sotto. PIMantecay ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Excavation ❑ Tracy Type of CasinDia. of Well Casing 1 ❑ Public L71 Other Other ❑ Delta Specifications Depth of Grout Seal Type of Grout Cl Irrigation --Approx. Depth ❑ Eastern Repair Work Done � T Surface Seal Installed by Type of Pump t? H p J State Work DonS Mery Well Destruction Cl Well Diameter Sealing Material (top 601 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LJ DESTRUCTION E3 (No septic system permitted if public sewer is Installation will serve: Other Residence_ Commercial available within 200 feet.; �� Number of living units; Number of bedrooms C Character of soil to a depth of 3 feet: A �I SEPTIC TANKWater table depth G ❑ Type/Mfg PKG. TREATMENT PLT. ElCapacity No. Compartments Distance to nearest: WellMethod of Disposal Foundation Property Line 1TLEACHING LINE _F3No. & Length of lines , FILTER BED Total length/size Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: WellFoundation 7 DISPOSAL PONDS F] Foundation Line 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. _ rmance of the work for which#his permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I certify that in th employ any person g i e perfosuch manner to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature tion laws of California." certifies the following: "f certify that n the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- The applican�t call for as i required ` q �pections. Complete drawing an Jreverse std , Signed C C� Title: A Lf S. ICED,1, Date: c�s� FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Dots0� `` Final Inspection by Date Additional Comments: �►-►�1 r ttrl y1 p•r h vrned in v lev h3 e vv> ❑ Stk 466-6781 ❑ Lodi -369-3621 ❑ Manteca tIZ3-7104 ❑ Tracy 835-6385 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUN�DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE HREl+ EH 13-24(REV.16/831 -EH 1426 F