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a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephtone (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. f �!�-l��n 4 Job Address 6_50- - m r bb JF I City A 641+ Lot Size PM Owner's Name i Y 1 ar IL Address Phone -57711 Contractor's Name 2A. Livens r� Phone TYPE OF WELL/PUMP: NEW WELL t WELL REPLACEMENT .❑ DESTRUCTION ❑ �( PUMP INSTALLATION L1SYSTEM REPAIR DI �' Oji-OTHER❑ ''"°.� DISTANCE TO NEAREST: SEPTIC TANK 100 SEWER LINES DISPOSAL FLD. PROP. LINE ` FOUNDATION -_.; ,r�=_-A RICULTURE WELL OTHER WELL-,"--- PITS/SUMP -_ X INTENDED USE TYPE OF WELL PROBLE AREA CONSTRUCTION SPECIFICATIONS /104 - 47 1 Y ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation - �' Dia. of Well Casing 9 Domestic/Private ❑ Gravel Pack ❑ Tracy � Type of Casirig y.�cs�P_4 Specifications ❑ Public ❑ Other ❑ Delta j Depth of GrAt Seal, ��ey :t. Type of Grout ❑ Irrigation i It_.Approx. Depth ❑ Eastern Surface Seal Installed 1iy TI+• n— n — Repair Work Done ❑ Type of Pum P �< p H.P. State.Work Done Well Destruction ❑ Well DiameterjSealing Material Ito Depth {Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION E�(No septic system permitted if public sewer is .. r , ! s.!. available within 200 feet installation will serve: Residence_ Commercial—i Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ! V Water table depth f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT-PLT. ❑ {I f Method of Disposal ��77 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines f Total length/size FILTER BED ❑ Distance to nearest: Weill Foundation Property Line SEEPAGE PITS ❑ Depth Sizei Number SUMPS r� -_ ❑ Distance to nearest: Well! ,Foundation Property Line 1 DISPOSAL PONDS "❑' -, .�_ - �:�..� .t g;.xy ..w. a mss,., �.. - -- 't• �,.. hereby certify that I have preparedth€r`appi€cation-and that the work will be done in accordance with San Joaquin county ordinances, state laws, and t rules and regulations of the San Joaquin Local Health District. Ho owner or licensed agent's si4nature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not Imp y any person in such manner as to become subject to workman's compensation laws of California.-Contractor's hiring or sub-contracting signature f certi ies 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 compansa- 1 tion 'laws of California." The pplicant muptpall for all requirednspe - ction mplete drawing on reverse side. tf Sign�d Title: Date: FOR DEPARTMENT USE ONLY � # '. -AppicationAccepted�by Date �! Area K Pit or yro t Inspection by ate� � -�- Final Inspection by Dat Additional Comments: s. ❑ tk 46647$1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 w ~ Ap leant- Return all copies to: Environmental Health Permit/services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Ct, � f, --w INFO FEE AMOUNT.DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. t 13-24(REV 101831 EH 1,11-211 14-