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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRI(__ 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Aliplication is hereby rnade to the San Joaquin Local Health District for a permit to construct and/or install the wor erein 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 I.ncal Health District, �r Jeb Address _�J_ri_�__1vf.__G OkAUt��T,�T City S� Lot Size PM Yy 1Q rte_ reo 1J �t-Kc� � �// Owner's Name Address S7 �jy_• SfV Phone3�8r� > __ r 5TDCA--M nI Contractorlj�(�(.(4 6(& Address_2g� 0 �y2IL� 5 T License No,�/aa��Phone TYPE OF WELL/PUMP: NEW WELL n WELL REPLACEMENT Cl DESTRUCTION f 1 PUMP INSTALLATION ❑ SYSTEM REPAIR f.1 OTHER Sf Flt1C NLS 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 I I Industrial v t_1 Open Bottom n Manteca Dia. of Well Excavation _ Dia. of Well Casing A)JA I)�Domestic/Private ( 1 Gravel Pack Cl Tracy Type of Casing I A Specifications _ 1 1 Public 1A Other 6U<; l+V L /7 pelta Depth of Grout Seal y _ _ type of Grout I LS 1 i Irrioatimn Approx. Depth I I Eastern Surface Seal Installed by _- Repair Work Done i 1 Type of Pump H.P. State Work Done Weft Destruction L.1 Well Diameter _ Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I (No septic, system permitted if public sewer is available within 200 feet) Installation will serve: Residence ___ Commercial Other Nirmher of living units: Number of bedrooms Character of soil to a depth of 3 feet: _ -- ,Water table depth SEPTIC TANK 11 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. t I Method of Disposal Distance to nearest: Well _ Foundation Property Line LEACHING LINE 11` No. & Length of lines Total length/size FILTER BED I I Distance to nearest: Well Foundation Property tine SEEPAGE PITS f I Depth Size Number _ A SUMPS i I Distance to nearest: Well Foundation Property Line v DISPOSAL PONDS U 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 Driltrict. 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 must ca/lljor II required inspections. Complete drawing on reverse side. 1` Signed X_ `-� Title: _St-_eb (*r—,q(17s�I s✓ Date: FO EPA NT USE ONLY y /� Application Accepted by Date /,S 1r� Area Pit or Grout Inspection by Date Final Final Inspection by Date Additional Comments: GG eV S . enc.-OgC4ft?rw)-- f Sik 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY (� DATEq PERMIT'NO- 3;4 rnev r r