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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ppY Ii �V D 1601 E. HAZELTON AVE., STOCKTON, CA RSG Telephone 1 PERMIT EXPIRES 1 YEARF FROM DATE ISSUED (Complete in Triplicate) 1��MNTAL permit to construct and/or install t �,� CHms application is s of the San Joaquin Application is hereby made to the San Joaquin Local Health District for a r� made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rule e�ulation Local Health District. jj� ,� Lam .' T �VF—R &'H I N C- AV I=- , City Srocie-<L kit Size PM Job Address W �Zdip SH 1TTf $ Q SI;ILiM,105-Q ,f`� 6 �1 Owner's Nam j�Q N 00' tt S � AddressZ Pho S7 MLRMs Contractor 1676 RISDON ROM Addres License No. Ag�.� Phone TYPE OF WELL/PUMP:.- NEW WELL WELL REPLACEMENT O DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ dj DISPOSAL FLD. PROP. LINE .— DISTANCE TO NEAREST: SEPTIC TANK �~ SEWER LINES �ip�p PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL S INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S tt VG pen Bottom ❑ Manteca Dia. of Well Excavation �z Dia. of Well Casing ❑ industrial VIC_ Specifications❑ Domestic/Private avel Pack ❑ Tracy Type of Casing r fl Other ❑ Delta Depth of Grout Seal Type of Grout�eiU`� M i Public % I-1 r igati '(� —.Apprax. Depth l I Eastern Surface Seal Installed by ��R if Work'Done lJ Type of Pump t H.P. State Work Done Well Destruction ❑ Well Diameter i Sealing Material{top 501 Depth �9 Filler Material {Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIRIADDITION I-I DESTRUCTION I!I availabe within 200 feet.No septic system )ied t pubic sewer is Installation will serve: Residence '' Commercial— Other Number of living units: Number of bedrooms - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK E3TypelMfg Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ize LEACHING INE El No. & Length of lines Total lenPro a gthlsrty Line r - FILTER BED ❑ Distance to nearest: Well Foundation P rtY . 1 f 1 Depth Size Number SEEPAGE PITS P kl SUMPS El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared ibis 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."Contractor's hiring or sub-contracting signature certifies the following:'9 certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." ' The applicant t call far inspections. Complete drawing on re rte side. Signed X ' Title: _, A��' Date: OR DEPARTMENT USE ONLY D to 7— 2-3 Area gr Application Accepted gg MW - aT� Ik Date Final inspection by - Date;� 1- Pit or Grout Inspection by ✓� Additional Comments: L] 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 S devoC-.bLC- Zk,— FEE AMOUNT DUE OUNT REMITTED CK RECEIVED BY DAVE PERMIT NO. INFO CASH EH 13-24(REV.»K5) 7 EH 1426