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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT R 1601 E. HAZE LI ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1yAR FROM DATE ISSUED I! (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. t .lob Address &'ct, o? P.4C_4f*= 6M7e_ _. _ City Ltl dl!I'I Lot Size PM y Owner's Name �� 1��. V 1' Address 7601'gf 1`k+Jr±4 .LA UdCA) Phone Address — — License No. o� Phone L3 Cont �• _ � TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 1K SYSTEM REPAIR C1 OTHER ❑ CSIN DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE FOUNDATION AGRICULTURE WELL OTHER WELL _ PITSISUM_PS INTENDED USE TYPE OF WELL PROBLEM�AREA CONSTRUCTION SPECIFICATIONS ❑ IndustrialO n Bottom ❑ Manteca r 14 Yr, Pe " 'r Dia. of Excavation Dia. of Well Casing 1:1Domestic/Private O-Gravet,Pack ❑ Tracy Typ;)of"&d$ing ,5 Specifications 1(,cOX 34J� F] Public C1 Other fl pelta Depth of Grout Seal , Type of Grout f1k irrioation 530 r.Approx. Depth I I Eastern St*cg f eel Installed by I �T _ � Y Repair Work Done L Type of Pump I C. H.F. t i State Work Dane 4flezrJ wed�s BvnD by Well Destruction ❑ Well Diameter Sealing Material (top 501 �1 Depth Filler Mateiial (Below 50'1 TYPE-OF-SEPTIC WOAK;—NEW_INST.ALLATION la REPAIRIADDITION 1.1 DESTRUCTION I I Mo septic system permitted if public sewer is jr 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 i t: ~"^ ---^— — •—Water-table-depth SEPTICTANK ❑ ;;Type1MfCapacity +yam _ _No Comparirtlents PKG.TREATMENT PLT.❑ ; ti ill" ,, Method of Disposal k Distance to rest: Well Foundation Property Line r LEACHING LINE ❑ "No. & Length of h Total length/sizei FILTER BED Q ,•Distance to nearest: Well Foundation Property jUrte I SEEPAGE PITS i I ::Depth Size Number I SUMPS 0 "Distance to nearest; Well Foundation Pro (Lina perty f DISPOSAL PONDS ❑ i I hereby cenify that 1 have piepared this application and that the work will be done in accordance with San 46Muin county ordinances,state laws, and y rules and regulations of the San Joaquin Local Health 011oict. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this pemut is issued, !shall 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,1 shall employ persons subject to workman's compensa- tion laws f alifornla." The !cant m a call fo all r PPl a uir inspectiana. Gogrplete drawing on arse side Signed Title: Date: i FOR DEPARTMENT USE ONLY Application Accepted by Date �� r3 Area-'# Pit or Grout Inspection by Date Final Inspection by� Date@ � Ir Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies'to: Environmental Health Permit/Services 1601 E. Hezelton Ave., P.O. Box 2009, Stk., CA 95MI I FEF AMOUNT DUE AMOUNT RITTED CAH CK INFO RECEIVED BY DATE PERMIT'NO. r+... i +.EH 11 142Z/ `IX6 1IREY.r�aal +..7 _ EEH -2e 77 ffj