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\/ 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. // APP Job Address City iC-r�►'7/�.Pnp Lot Size 00 �� PM Owner's Name�t �f4 r/,QCS cGL-.S Address Z�i5G JJ ri +A / Phone Contractor..010.Z.j1 _iv Address "-;Ey /0294+4 License No.;1 T 2. Phone / 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 L] Industrial ❑ Open Bottom ❑ Manteca 'Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public f-1 Other 11 Delta Depth of Grout Seal Type of Grout--- ] 1 Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) 6 Installation will serve: Residence_ Commercial Other Number of living units: _ Number of bedrooms ,Character of soil to a depth of 3 feet: 594-,bSEPT24 D0 RC Water table depth PKG. T TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line 'LEACHING LINE ❑ No. & length of lines q Total length ize FILTER BED Distance to nearest: Well /.SO�TFoundation Property Line S�EPAGE PITS I I 'Depth - Size Number SUMPS Ll Distanctf to nearest: - Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 law6.of California."Contractor's hiring or sub-contracting signature certifies the following: "1 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 required inspections. Complete drawing on reverse side. Signed X------ Title: Date: oG FOR DEPARTMENT USE ONLY ',►L-�/ Application Accepted by _ Date it ' Area /3 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: AlQ ve a "✓1 k rte` ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 O fracy 635-6385 7 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �. INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH11241REv.vxsi —yam . AE O EH 1420 ! �4/