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APPLICATION FOR PERMIT SAN-IOAQUIN 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. / /A✓J- �/ j� rfr Job Address � ` ' /V(� City • q 7Qt: Lot Size�1J -� /f 77, Owner's Nam/e/l�.IS.SLL1 • /l LI, P(^ Address �V �J '' (u , , -" [��y, /-J�11—Phone P� `-7f 9- Contractor L a&,rot4w Address C License No.]_J3./_:51—Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ;DESTFWCTION ❑ PUMP INSTALLAT O ❑ SYSTEM REPAIR ❑` 'OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.�_ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �a .INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIdj4s A (I dustrial ET-0 pen Bottom Manteca Dia. of Well Excavati Dia. of Well Casing r Cl Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications 16a Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout r L7 Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. '_ tnaatte/Wor Done \ Well estruction We Diameter ` Sealing Material(top 50'1 � l/ n Irl p J ('P4D be, 01 �_e�'t") Filler Material (Below 50') (A 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, Number of Irving units: — Number of bedrooms j _ Character of soil to a depth of 3 feet ) Water table depth SEPTIC TANK © Type/Mfg I CapacityNo. Compartments PKG. TREATMENT PLT. ❑ I t• Method of Disposal Distance to clearest Well Foundation Property Line V - -_ LEACHING LINE ❑ No. & Length of lines t `• � Total length/size FILTER BED ❑ Distance to nearest!* Will Foundation Property Line SEEPAGE PITS /Depth Size Number SUMPS �', ❑ Distance to nearest: �.-Well Fouddation Propos Una DISPOSAUfONDS ❑ 1 I hereby testily I h ve prepared this applVFation and that the work will be done in accordance with Saw Joaquin county ordinances, state laws, and rules and regular' qa�th0 San Joaquin Local Id}alth District. Home owner or lice 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 arty person in such manner as to become auD' t to workman'scompensation laws of California:'Contractor's hiring or sub-contracting signature cartiCbs the folbwing:"I certify that In the perfomrane qy the work for which this permit is issued^I strall empty persona subject to workman's compensa- tion Is of Cal'dornia:' ..._. - The applicant rr4 for II red inspections. Complete drawing on rev side. _ r S]�RSJ Signed Title: Date: �� FOR DEPA TMENT USE ONLY I / -c+�Area C/ Application Accepted by !/z/� Dare - �—/ '7� Ph or Grout Inspection by (ate 8�0 nal Inspection by No Date Additional Comments: ❑ Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95WI FEEgMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO � A i EH 1124 IREV,r i a Si 70"0 Gk {'►'v �—+'f� 793 EH EH 1416