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4 APPLICATIA FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZI L T ON AVE., STOCKTON, CA T41ephone (209) 466-6781 PERh4IT EXPIRES 1 YEAR FROM DATE ISSUED (Complete 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 Local Health District. Job AddreBs 77Qijh0 / S Ciry t of Size - PM Owner's Name Lu L 72[:w.. 6 IM-P �5 Address l #�f�i/ &1,1_1vp 5 f S Phone Contractor E�' [GSC ��t7 tw C1 Address y)4 f�L t _JG ,D! Q License No �C)Phone`(O,?-- t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ i' DISTANCE TO NEAREST: SEPTIC TANK s . SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL :,j PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom + t ❑ Manteca Dia.`of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I' ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i # ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by `f Repair Work Done )IQ Type of Pump 5 A.L2,-- H.P. State Work Done ke 12 4i, 40 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑." REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is fiavailable within 200 feet-) i Installation will serve: Residence's Commerc,ial— 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 f Distance to nearest: Well -Foundation Property Line F LEACHING LINE'. ❑ No. & Length of lines _ Total length/size FILTER BED,' LY Distance to nearest: Well Foundation- "Property Line SEEPAGE PITS t ❑ Depth Size Number. SUMPS o ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ •' I hereby certify that 1,,Qe,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 ih such manner as.to become,subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature h 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." `*. 't The aj�pwant-lkipt call-for alhrequir inspect' ns. Co lete drawing on reverse side. R / i Signed X f hf Title: Date: " P FOR DEPARTMENT USE ONLY Application Accepted by ,' i Date Area '16 i i Pit or Grout Inspection by Date Final Inspection b`-21Dat . . , r '1 Additional Comments: ❑ 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 q FEE �1 INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. ' 0, +EH 13-24 IREV. /a 5S ; - of�9 7 3g EH 14-28 ` cJ