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v APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1 D 1601 E. HAZELTON AVE., STOCKTON, CA AIN " r c , Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN LOCAL i (Complete in Triplicate) HEALTH DISTRICT, Application is hereby made to the San Joaquin Loral 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 �l] r"�+'Ci7i/'Cy-�.sity /r4, PM Owner's Name liLZ1CQat-� ddress g33�J�<i��Phone z/ Contractor's Name .(�-'-`f �-L plp, /G L 3 73 Phone TYPE OF.WELL/PUMP: NEW WELL ❑ / WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION IY SYSTEM REPAIR *- OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ trial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ZLSYDomestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _ / ---Approx. Depth ❑ Eastern - Surface Seal Installed by 'IN Repair Work Done (J Type of Pump :5�1&. H.P. -Z State Work Done (/1 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other }t Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments / PKG. TREATMENT PLT. ❑ Method of Disposal P Distance to nearest: Well Foundation Property Line JJJggg LEACHING LINE ❑ No. 6 Length of lines Total length/size [" FILTER BED ❑ Distance to nearest: Well Foundation Property Lim SEEPAGE PITS ❑ Depth Size Number , 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 rules and regulations of the San Joaquin Local Health District. Home owner or licen nt'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 pe n such nner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certities the f wing:"1 ce that in the performance t/workwhich this permit is issued, I shall employ persons subject to workman's compensa- tionlaws alifornThe appli nt mus o I requ d ' omplon revers side. ev Signed A _V-1L '" '"i�Z�%-'6l/f��°" ate: b /! FOR DEPARTMENT USE ONLY Q Application Accepted by i`Mink. q Date (0 t+ Am + Pit or Grout Inspection by Date Final Inspection by Date �� 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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED GSM RECEIVED BV DATE PERMIT-NO. ,.". .. . ,,, 1 U- 17 b/,