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0Zso22,D o 2 M APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E HAZELTON 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 Thrs application is made in compliance with San Joaquin County Ordinance No 549 for sewage or No 1861 for well/pump and the Rules and Regulations of the San Joaquin Local Health District yy�� Job Address _ �rar{}�I�+c 11CtT City Lot Size 4" 6_x'3 A'X PM Owner's Name }'ane( M-ol lhc, Address 1A Ll F. 66,4-4116C Roa►pf Phone -S - S Contractor e } - Address '2'10 N- EcTr =579fgg License N91- a Phone f r 1 TYPE OF WELL/i'Eiif- NEIN WELL Cl WELL REPLACEMENT O DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER !'nc tIL(j� DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLp PROP LINE �Nti4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1$ Industrial- +��i4c7 C1 Open Bottom ❑ Manteca Dia of Well Excavation/I i'ne6 ,,, pia of Well Casing ❑ Domestic/Pnvate J E�Gravel Pack 1?.Tracy Type of Casm Speaficat+ons ❑ Public ❑ Other ❑ Delta Depth of Grout Seal �4 Type of Grout l,c 2.mea L ❑ Irrigation _—Approx Depth ❑ Eastern Surface Seal Installed by ! Repair Work Done ❑ Type of Pump H P State Work Done Well Destruction ❑ Well Diameter Searing Matenal (top 501 Depth Filler Matenal (Below 501 40 PE OF SEPTIC WORK NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted d public sewer is available within 200 feet I 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 CapacityNo 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 ❑ Depth Size Number SUMPS ❑ Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ 1 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"Contractors 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 appl+ nt ust call f fr 11 required inspections Complete drawing on reverse side LLC&- - DateJp Signed Title _C 0Af nf� L�-l./r' Ti a-6 ,� _ FOR DEPARTMENT USE ONLY Application Accepted by Date Area 0Pit or Grout Inspection by Date Final Inspection by Date -b0nal Comments ✓ ❑ Stk 466-67$1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6311,5 Applicant- Return all copies to Environmental Health Permit/Services 1601 E Hazelton Ave, P O Box 2009, Stk , CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO EH 14-20 INFO 1111124IREv heal