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_ � U 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. l Job Address 14 C/ � GLOM gE �;_ _ - City/O la Lot Size ZZ // t2 S PM _ �( Owner's Name __ _I __Ll Address �� -5r't A�P,h ID—d— Phone _ _ Contractor VA ffe t f� h AddressI' •1 ]C'J �� ("74 IT License Noc f Phone TYPE-OF WELL/ - ,NEW WELL, _ WELL-REPLACEMENT-0.__ .DESTRLt TION_L1_'... PUMP INSTALLATION>L_ SYSTEM REPAIR ❑ OTHER, ❑ ; DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLDf�Q PROP. LINE CPO FOUNDATION AGRICULTURE WELL OTHER WELL jtbhY_ PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATJONS ❑ IndustrialOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casino Specifications c7 _ f'1 Public 1-1Other F) Delta Depth of Grout Seal O Type of Grout's:NL _. I Irrigation -� O_Approx. Depth . I I.Eastern Surface Seal Installed by (ZdZ e V nf! �1 _ Repair Work Done L] Type of Pump � H.P. State Work Done Well Destruction ❑ Well Diameter ' * Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRlADDITION l I DESTRUCTION l 1 Wo 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 Capacity No. 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 Ll Distance to nearest: Well Foundation Property Line F> 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, a� 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 m s ca for all required inspections. Complete drawing on reverse side. Signed X�_Zgl n � 'N G- AA,.iAA91�, Title: '::Se--,- /S��e S Date: 1 OR DEPARTMENT USE ONLY f Application Accepted by �„d� � c�><w...C�.� Date Area 1 PitGraut)spection by %f�;�4 Date Final Inspection by - -1�f 6�� G Gid Date� � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH1 3-241REV.I/K5) rrrr�-� 3 `0© ■1 f EH 14-28 V �� - a~�T-jd