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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I 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 5 City�` - Lot Size PM Owner's,Name �LILIgll)(A t ( 10111` Address !�&ol ! ee.ioe-re t• Phone Contractor's Name License No. Phone <re[ 96_d7_7 ` ... TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT C1 DESTRUCTION LJ V ! PUMP INSTALLATION ❑ SYSTEM REPAIR"❑ .� �� OTHER ❑"' " 1 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 ❑ Industria! Open Bottom--El Manteca Dia. of Well Excavation Dia:of Well Gesing- f ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 13 Public 1 LJOther C1Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ ,hype of Pump _P1 tH'P* �� ' State Work Done i Well Destruction ❑ Wel! Diameter Sealing N�aterial [top EO'l' Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION �X DESTRUCTION ❑ (No septic system permitted if public sewer is ; available within 200 feet.) € Installation Will serve: Residence Commercial-6/Other Number of living units:: �^ Number of.be_&ooms �� I Character of,soil-to a depth of 3 feet:j p SEPTIC TANK! tE( Type/Mfgapo? fdrrf�Co"rn,,nartments PKG. TREATMENT PLT. ❑�`ti t� y- A - — 6th !6�f�ls Distance to nearest: ell Foundperty Ion - -' - LEACHING LIN_E ❑ No. & Length of lines Total length/size % FILTER BED ❑ Distance to nearest: Well Foundation Property Line "a p SEEPAGE PIT's ` �e' Depth; —,Size Number #10 SUMPS ❑ ism ncl �o nearest: Well Foundation Property Line ,-r,._, _,•,� DISPOSAL P NDS ❑ -L,ftp t I hereby certify+that I have prepared this application and that the work wil be-o ne in accord wit an Joaquin ounty ordinances, state laws, and 1 rules and regutdtib 16Tof'tlie-'Sen Joaquin'Local'Health*bistrict. Y X I Home owner or licensed agent's signature certifies the following: "I certify thatin.the performe f the' r for ich this permit is issued, I shall not I employ any person In such manner as to become subject to workman's compensatfo.n laws'b1f`california."Contractdf hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for whi�h thislipe'rmit is issued,.).shall erf&gy persons-subject to workman's compensa= tion laws of California." f' The applicana st cal f all required inspections. Complete drawing on)reveyrse ide. Signed Title:&�f �GS Yt�G1� Date: FOR DEPARTMENT USE ONLY Application Accepted by _ •-•'`Date _ Area Pit or Grout Inspection by ate Final Inspection b Date )t eii Additional Comments:- �' Stk 466-6781 ❑ Lodi f3sq, 1 ❑ Manteca -7104 ❑ Tracy 6385 µ i App is t- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE MOUNT DUE AMOUNT REMITTED CASH . . 'RECEIVED BY DATE PERMIT NO. + EH 13-28IREV.101831 ....�"" �,n*('" �EH `� �P e -1 A {� . I