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y� � 1 Yi ip t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I 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 s Local Health District. ' u1/ - Job Address _�✓ ! 0 City t' 0'w' Lot Siz I' / Le PM Owner's Name' �+�5 l Li+�yLsLilea S Address � zL G �uJ�+KPhone 2S 6 -00 's RGf��s tck�to� 'W".r' ho ,,• Z}_6 S-S —F Contractor's Name License No. -- 'Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT U DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -N96--i +DISPOSAL FLD. PROP. LINE FOUNDATION> AGRICULTURE WELL*` 1 OTHER WELL "PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEMAREA" CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantecar Dia. ofWell Excavation !-A-`i+ Dia. of Well Casing El Domestic/Private El Gravel Pack LJ Tracy 10IType of Casing -.: - "%Specifications ❑ Public ❑ Other E ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal-Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction LJ Well Diameter Sealing Material (top 50') Depth 1 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ (REPAIR/ADDITION ESTRUCTION ❑ (No septic system permitted if public sewer is s available within 200 feet.) a Installation will serve: Residence_ Commercial-K Other 4 �, Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ,Q.ItAgj .� �- p # � Water table depth SEPTIC TANK ❑ Type/Mfg 4Z Capacity No. Compartments S-- PKG. TREATMENT PLT. 171I Method of Disposal Distance to nearest: WeII Foundation Property Line .I e LEACHING LINE No. & Length.of lines ri Total length/size T FILTER BED ❑ Distance tonearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth •Size Number A21rqf SUMPS rt Distance to nearest: WeII 'tt--'Foundations Property Line __ DISPOSAL PONDS ❑ 1 t 00 T �- 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: "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." Contractors 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 must call for all required inspections. Complete drawing on reverse side. e p I Signed + Title: b ojV-4.L Date: 3 14 i FOR DEPARTME SE aY rr Application Accepted by CWDate Area �7 Pit or Grout Inspection by Date Final Inspect+ n by Date`:� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-362i' ❑ 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 s + FEE INFO AMOUNT DUE AMOUNT REMITTED ECASH(( RECEIVED By DATE PERMIT�}NQO. i + EH 14-2q(REV.10/831 - c�I].�4S r-�' !�� 1 / � 3-- 1 — ^U y+ EH 1428 ; I7� ? __,_ 11 !! ll J