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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. Job Address gZa3 VJeS-r ITh -St ` City Lot Size PM � ) 1 /l^ /1 N1 ,f /�� -�l ,+ C/LtsC. Owner's Name Uno�Al C� Address z•1 ,� N. lH'(r �l�l/(� tf(0� Phone ContractorWCST nPr'u/fls'* Address 13335:EV:fA6 &y4UX7 License No057 '554975Phone CiAP /n3Sn-:7oo 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 rr ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 56h 40 FV6 Specifications 11 Public Other rkYI!' 71 Delta Depth of Grout Sea— I Type of Grout G2Men+ 1 I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by A"WhAf� _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Qoett's4V Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is ^ . available within 200 feet.) y/ Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms G 0 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 I I Depth Size Number t' SUMPS ❑ Distance to nearest: Well Foundation Property Line 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, and�'j rules and regulations of the San Joaquin Local Health D3trict. 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, Lshall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractoes 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 call for all required Inns-pectioonns. Complete drawing on reverse side. M Signed X Title: ae 0-* / (GuA�e_ EData: 1, FOR DEPARTMENT USE ONLY Application Accepted by c Date_j2t� Area ` Pit r Grou Inspection by Date �O• 2 y' i Qinal Inspection by Date I Additional Comments: JJdL.l l.es �� 7 QAW\4-6 QKI 4VkaCA, ❑ Stk 466-6781 ❑ 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, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REM1 D CK RECEIVED BY DATE PERMIT'NO. INFO ��••••�� }}�� ma�yy;; . =}-211REV.t r x e) 2ST9 LL% Y-t �V^J `Q o b-4;2x)- -