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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. /J 1,, 1 Job Address /tf j 12 wl( 'A " - _ City Lot Size PM VIA Owner's Name Address Phone Contractor Ml� 5 �5= Address License No. l7 9_146 Phonez�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONS PUMP INSTALLATION ❑ vn SY5EM REPAIR 0 OTHER ❑ 3 DISTANCE TO NEAREST: SEPTIC TANK StV*ER'LINES J '"1 �>`DISOOSAL FLD. PROP.-�iN6—' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS: �== INTENDED USE TYPE OF WELL PROBLEM1A"AREA — ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation r` 1 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy �tye-9f.CasingP'`� ,f Specifications FI Public 171 Other ❑ Delta Depth 0PG�rout�al� Type of Grout _ I I Irrigation —.-Approx. Depth I ) Eastern Surface Seal Installed by } Repair Work Done ❑ Type of Pump �,_,_, H.P. State VJlork Done /11r 9 Well Destruction 47 Well Diameter Sealing Material (top 501 Depth 30 Filler Material-(Balow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIR/ADDITION I I DESTRUCTION 11 INo septic system permitted if public sewer is " available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 4}� , Number of living units: Number of bedrooms 1 lY+ t� '4 (] 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 Distance to nearest: Welles Foundation Property Line LEACHING LINE L1 No. & Length of lines `yl�--k ^� Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line Q SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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."Contractor's hiring or sub-contracting signature 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." The applicant ' s a aE squired ns.'Complete drawing on reverse side. Signed �` Title: Date: _Z! 72/2 " .— R DEPARTMENT USE LY Application Accepted by VLA A�r�/ y�L�A:.� ,.„ Date u"L Area_4 W11 Pit or Grout Inspection by Date Final Inspection by bQ/�/V� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERNIiT ND. +.EH 13"21 fREV'.tin5J V��`O0 I.� �) EH 10-2a 4 -�p{K]