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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1603 E. HAZEL T ON AVE„ STOCKTON, CA Telephone (209) 466-6781 PERMIT 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 Address �� ~ -S P$7 12 Li • 1 ()A Cl City MA&1; Lot Size PM Owner's Name A m, Address. r' oAl s- -C Phone Contractor (Q)16W> Address.. License No. ` Y'i 7s7d Phone 97 TYPE OF WELL/PUMP: NEW WELL I$ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PiTS/SUMPS :_= INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r ❑ Industrial ❑ Open Bottom �(Manteca Dia. of Well Excavation Dia. of Well Casing )Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Othe.l;__ Cl DeltaO.epth of Grout Seal Type of Grout _ `I-lrrigadon•_ Approx. Depth i I Eastern � Surface Seal Installed by � t Repair Work Done ❑ Type of Pump H.P. State Work Done_ f Well Destruction ❑ Well Diameter +Sealing Material (top 501 Depth i Filler Material (1]16(0yy 501 + TYPE OF SEPTIC WORK: NEW INSTALLATION OR EPAIR/ADDITION,I 1 `D15STRUCTION I I lNo'*eptic system permitted if public sewer is 1 , ':J available within 200 feet.) Installation will serve: Residence Commercial_ Other f Number of living units: --/—, 'Number of bedrooms Character of soil to a depth of'3 feet: Water table depth i SEPTIC TANK ❑ Type/-Mtg_._ .._ G _Capacity 1 w No. Compartments y PKG. TREATMENT PLT. ❑ j Method of Disposal Distance to nearest: . Well 007- Foundations Pro ert Line " fes:_ P y. . -- LEACHING LINE No. & Length of lines _ f C1 � I� 7�9 �' � l� lal length%size- FILTER BEDS'J , ❑ Distance to nearest: Well Foundation `�� Property kine �. .. GE PITS (art:;Depth Size — Kumber F L- Distance to nearest: Well1 Foundaton j ! Pro,operty Line DI OSAL PONDS ❑ f I hereby certify that I have prepared this application and that the work will be done in /accordance withISan Joaquin county ordinances, state.laws, and rules and regulations of the San Joaquin Local Health Di$trict. Home owner or licensed agent's signature certifies the following: "I certify that in the performa&6 of the work for which this permit is issued, I shall not £4 employ any parson in such manner as to become subject to workman's compensation larws of California:"-Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permii is issued, I shall fir ploy persons subject to workman's compensa- tion laws of California." 41 {11 The appliA, str all required inspections. Complete drawing on reverse side� Signed X Title: Date: _Z0- 0 L O— O EPARTM USI~�ONLY 10 Applicatiopey Date ! ` / 0 Area / 3 or Pit or Grout Inspection by Dat f Final Insp ctioh by Dat ' Additional Comments: 411B ❑ Stk 466.6781' ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 &COW �jVa Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE / 1 INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. +.EH 13-24IREV.ri65) EH 14-29