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A 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 1Complete in Triplicate) •l .t1 ' 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 � s� City Lot Size C 1rr-.- PM C�vEsfi C) Owner's Owner's Name ��_ Address '01 '' - - Phone ` Contractor's_Name L E-�_ 1I��L�1 ta-license No. � + _ �� Phone -TYPE OF W_ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ PUMP INSTALLATION'❑ SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST; SEPTIC TANK _ SEWER LINES _ DISPOSAL FLO. P410P. LINE FOUNDATION AGRICULTURE WELL OTHER WELL.- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIpN SPECIFICA-IONS"— ❑ Industrial G Open Bottom ❑ Manteca Dia. of Well Excavation_ ('Specifications of Well Casing _ t ❑ Domestic/Private " ` C Gravel Pack ❑ Tracy Type of Casing t Specifications ❑ Public, C Other ❑ Delta Depth of Grout Seal ;Type of Grout_ ❑ Irrigation,, 1 s,f --Approx..Depth ❑ Eastern Surface Seal Installed by__ - a f / Repair Work Done G '. Type of Pump H.P. State Work Donee ' Well Destruction ❑ Well Diameter Sealing Material(top 50') f Depth - -. - - Filler•Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION F1 DESTRUCTION ❑ (No septic system permitted if public sewer is N I T t _ 1 ..- ' available within 200 feet.) . Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet:i �1��3 t"✓r 4- Water table depth V SEPTIC TANK e❑ Type/Mfg '3 j f t Capacity' '`1, " ... rNo. Compartments" PKG. TREATMENT PLT. ❑ ��'� �-• �.; �`= .� Method of Disposal Distance to nearest: Well� ?- Found tion ! ProperEy Line f� _ y t LEACHING LINE &L,No. & Length of lines D Total lengthlsiz`e FILTER BED ❑ Distance to nearest:. Well 1 Foundation ; r Property Line SEEPAGE PITS Depth Size -"e - — 'Number SUMPSC .Distance to nearest: Well ICD 'Foundatitirn �J` F r4 rty Line _ l DISPOSAL PONDS 111111 c c: A•. � 1 I hereby certify that I have prepared this•appiicatioh and that-the-work will be done in accordance with San Joaquin county ordinances,state laws,anis 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'scompensation 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."t The ust call r II ra 'red i ctio omplete drawing reverse ide. I f Signed ^E 71 ii .(�(JI U ci _ Date: O i I ` FOR DEP RTMENT USE ONLY Application Accepted by A Date ~� Area Pit or Grout Inspection b Date Final In _ y , Inspection by 4 ' Date l G Additional Comments: Q&,Q F/�! I/ll�iPa r�1 7`�( �Illr►17 1�77f39 �jri�57Tit�6 C!�/� Qi �G�/ ❑ Stk 466-6781 ❑ Lodi 369-3521 ❑ Manteca 8h-7104 ❑Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201, diff jLli((�i f 1 i INW 'AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMn"'NO. +EH (REV.10/e31 EH 1128