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it 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 (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. rkD tS L(So f Job Address —71q? �c l of Si,,Z A fI'e- PM 73L Owner's Name c,grt -YI VIS -FrCO(MCkyyA�2ddress 1976 Lo vi,,,..bO. rd gSAVt FYG!1 Phone 4 3`_O ContractbrTl,t fr U �w Address T.nz Bt .SR0s JICK UN L �Ne.5.2166 Phone 1� _-5 6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O ' DESTRUCTION PUMP INSTALLATION Ld" SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 150 SEWER LINES 150 DISPOSAL FLD.J_CQ_ PROP. LINE 2.190 FOUNDATIOND� AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing VDomestic/Private 0/bravel Pack ❑ Tracy Type of Casing :P V L Specifications �1 I.1 Public Cl Other Ll Delta Depth of Grout Seal loo, T �P.6ftQNT xpe of Grout I I Irrigation —Approx. Degqpptt�h�� I I Eastern Surface Seal Installed by C41 ulcrkyUYl 111 K9 _ Repair Work Done 0 Type of Pump t2 H.P. ;Z State State Work Done M1e.lo15nn1 11 new we.11 Well Destruction fg" Well Diameter $ Sealing Material (top 50'1 [\ Depth Air Filler Material (Below 509 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is (� 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: Water table depth . SEPTIC TANK Ll Type/Mfg _ Capacity No. 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 SUMPS Ll 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 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's compensation laws of California." Contractors hiring or sub-contracting signatur 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 c tion laws of California." ompensaI- The applicant must call for all required inspections. Complete drawing on reverse side. \\ � J Signed X Title: —(Jy9 )L8G7 Date: /��/II //// �,/// FOR DEPARTMENT USE ONLY ,A Application Accept y �"' Date Area Pit or Grout Inspection by Date _ Final Inspection by Yl Date Additional Comments: U ❑ Stk 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 r( FEE INFO AMOUNT DUE AMOUNT �(REMITTED `C{A�S1FH ,,R RECEIVED BY 1y, DATE ry^�s. PEIRM17 NO. nD�I��W,�L{1 rEH 1}24(REV.I/R51 C�� 1 I��tA, I I 111.f�1 I ' /' "1- ��q EH 14-2a