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'%w APPLICATION FOR PERMIT "'W 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. G/l Job Address oCJ 074 / (My� 7'7 ICS 1 film' SCh s_ny� /�,�`A�jLot Size PM Owner's Name ni oI )()A3��AI l w Address s� �� e� !/7m'I4 sI6 `.c-� �) ��-- Phone 7� Contractor/�1—'Y190&,!6 `DAA a Address ZIW WlIEok�c)z _ License No. Phones.)_3`-"6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU. PROP. LINE FOUNDATION 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 y ❑.Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications �%— ublic FI Other fl Delta Depth of Grout Seal Type of Grout_ C I II Irrigation _.Approx. Depth I I Eastern Surface Seat Installed by p -_ Repair Work Done L] Type of Pump H.P. State Work Done ' / Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Fillet Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest Woil Foundation Property Line LEACHING LINE ElNo. 8 Length of lines • Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line V) SEEPAGE PITS ,\ 'I,I Dfpth r/�5i2e _ Number SUMPS t `❑i IEllstance-to-rfea erst: W Foundation Property Line DISPOSAL PONDS ❑ I. I hereby certify that 1-have prepared this application and t at the work will be done in accordance with San-Joaquin county ordinances, state laws, and rules and regulations oljlhe San Joaquin Local Healthric[. Homeowner or license3 agent's signature certifies the following:)cokitylthat in the performance,of the work for which this permit is issued, I shall not employ any person in such manner las to becorme subject td'workrgiyrlIs comjtInsation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the-p9rformance of th "wo -itoor which this permit is issued, I shall employ persons subject to workman's compensa tion laws o(California:" JJ The applicant rZ ired ' are drawing on reverse go,— Signed X _e IFI9L Date: FRR DEPARTMENT USE ONL / )�--- Application Accepted by Date Area Area �1z✓ Pit or Grout Inspection by Date Final Inspection by .�i Date Additional Comments: ❑ Stir 466-6781 ❑ Lodi ,369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environrr(ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. x EN }211REV.r/x51 1 3-5 .lam A ' EN 1424 �T ( 1 p