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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 Ryles and Regulations of the San Joaquin Local Healt istrict. �QS p t `_ Job Address I l� S' CV�'erUK.eR- City L1 04A Lot Size PM Owner's Name tL-�-tO 0: 1 60• Address IZZI t• #141H 5}.,CNc(TtRHM+l,V Phone Contractor O-f Qtby_x, Address � ' NJIItJ oW4A; c& License No. Phon �/ - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatign - Dia. of Well Casing E, Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing / JC. ,. Specifications Pe }icaT-/�O/1/ h'rl -Other ❑ Deka Depth of:Grout Beal Type of Grout Irrigation � O pprox. Depth ❑ Eastern Surface Seal Installed by - Repair Work Done ❑: Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION O 'DESTRUCTION ❑ (No septi, system permitted if public sewer is available ivithiri 200 feet.) Installation will server Residence_ Commercial_ Other ` j Number of living units:'—- -'Number of bedroon s— - - Character of soil to a depth of 3 feet: r` Watei table depth SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments,. PKG. TREATMENT PLT. ❑ - - - Method of Disposal I Distance to nearest: Ylfefl Foundation Property Line LEACHING LINE ❑ No. & Length-of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth e Number SUMPS ❑ Distance to nearest: Wel_ Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and drat 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:"1 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: "1 certify that in the performance oftfte work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant b call for all required inspe eons. C e drawing on reverse slide. 4070 Signed X-- -- Title: date: a _ R EP T USE ONLY G� C Application Accepted b ' Date `z GG Pit or Grout Ins cti y _ .Gtr 3-22-W Final Inspection bye Date Additional Comme Stk 466-6781 I.1 Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 Applicant - Return ail copies to: Environmental Health Flaimit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.. CA 95201 APR, ----- FEE AMOUNT DUE AMOUNTflHNITTED RECEIVED BY DATE PERMIT NO INFO CASH OLT— IH 1:1 24 IRrV .. & -. J1�1 L 11 2h I /^/ J r J