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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DIS 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 Ilv PERMIT EXPIRES 1'YEAR FROM DATE ISSUED DEC 5 10 (Complete in Triplicate) EN,, '-NMENI�TTppA��L((�rHEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein das40&wNTI�isSap Q§,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 Address I V �IGNx(O"�' `TA City Lot Size PM Owner's Name f/licrw�' `�r'r"� �5 Address ft7.� S /Garzr•tK i Phone7 / 80 �e!'n0/J Sf,.Stt_3 d1Gs�'Sb Contractor G Gtit Address OStd/ (/Y 2Z License No.SCL/ C57 Phone 7�3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �u 18X,171 csrj DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ROP. LINE FOUNDATION AJ 2a/ AGRICULTURE WELL OTHER WELL PITS/SUMPS 6!L_15 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 11f} CTO pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ` ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing — / Specifications 11 Public ❑ Other ❑ Delta Depth of Grout Seal N 269 Type of Grout I I Irrigation —Approx. Depth 1 1 Eastern Surface Seal Installed byA�zr..�S'o.,, _ Repair Work Done ❑ Type of Pump H.P. _ State Work Done Well Destruction O Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION I I DESTRUCTION 1 I INo 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 CapacityNo. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No._&-Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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."Contracto/s hiring or sub-contracting signature certifies the following:"I 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 applic t call r all ``uirrred inspections. Complete drawing side.ssiidoe. r, Signed W— Title: 1z�aGri�C wf Dale: D FORD ARTMENT USE ONLY Application Accepted by /� Da t4 ( `� Area �_6 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 O 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 FEE INFO AMOUNT DUE .fAMOUNT REMITTED CK RECEIVED By DATE PERMIT NO. .EH IdN EH It-a!