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) APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 0 1601 E. HAZE'LTON,AVE:;,STOCKTON, CA Telephone (209} 466-6781 J' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 71.1 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. 1882 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ` �,� D_/ Job Address _� �z�d 7 ' l PS IC a r City /ke4le �"Size PM Owner',s NameAL— C 4 -P" Address ��' d Phone QZ� ` 2373 cs G�-�6Z Contractor's Name A4 AUA", - License No. �Q Phone .OF NW WELL WELL REPLACEMENT DESTRUCTION ❑TYP 7 PUMP INSTALLATION 9--' SYSTEM REPAIR ❑ O },iF�t�❑ DISTANCE TO NEARd'f: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ;�. FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS NTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION Industrial '�"�❑�0 n Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing ❑ Domestic/Private } C�]'Gravel Pack ❑ Tracy Type of Casing % Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal TVpe of Grout ❑ Irrigation __._-Approx. Depth ❑ Eastern Surface Seal Installed by A414Repair Work Done ❑ Type of Pump 1A 12 H.P. s State Work Done Well Destruction ❑ Well Diameter + Sealing Material (top 50') I I Depth Filler Material (Below 501 TYPE OF SEPTIC WOR : NEW INSTALLATION ElREPAIR/ADDITION El DESTRUCTION El (No septic system permitted if public sewer is available within 200 feet.) 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT' ❑ Method of Disposal rill Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 t fh jL 1 SEEPAGE PITS Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C] hereby certify t ve prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and re tions of t San Joaquin Local Health District. Home aw r or licensed ais signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ y person in such. nner as to beco a sub' workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifie the following:"I c that in th ce the wor or which this permit is issued,I shall employ persons subject to workman's compensa- tion la of Calif nia." t The a plicant muAt r all io Comple drawing on revers F 1 Signe Title: _ Date: ! POR DEPARTMENT USE ONLY i Application Accepted by � D Area CJ8' Pit or Grout Inspection by Date ---1,V4 Final Inspection by a ' Date/ iA Additional Comments: i fine LJStk 466-6781 ❑Lodi 30-3621 El Manteca 823-7104 El Tray 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 VL t FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY, DATE PERMIT�`NO. INFO CASH + EH 1324 iREV.10/831 .. �t� $ S;,Li EH 1428 001 X1..1.-S?�►p �-� I