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06/06/2006 15:20 4640138 ENVIRONMENTAL HEALTH PAGE 03 5 �l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZFLTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hensby 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 compisnce with San Joaquin County Ord rence No.649 for sewage or No. 1562 for wag/pump and the Rules and Regulations of the San Joaquin Local Heatth District , . Job Address *J/C 'm( Chy aA9±4qy---- Lot Size At PM Owner's Na Address '2617 o & a� Phone rr Contract Address PA _ License No.i2�'6�r-Phone !o —Slf9 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP,UNE FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS _,,... INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Indagtriel ❑Open BetWm ❑ Hamate Dia.of War 5roavation Die.of Wel Casing . ❑ Domestic/Potato O Gravel Pack ❑Tracy Type of Casing Spedfrcedars ❑ Public ❑Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Imgation —Approa. Depth ❑ Easton Surface Seal Installed by a f Repair Wo.k Done 0 Type of Pump H.P. State Work Done V Wen Destruction ❑ Wag D'arneter Sealing Material (top 501 Depth Fri ler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRTADDRION ❑ DESTRUCTION❑ (No septic system permitted If public sewer is avalk"Is within 200 feet.) Installation wx serve: Residence Commercial_ Other Number of Erving units:--41— Number of b1.. porus .._. .. .. ... . / - , ... - Charaeter'ef so-iY to a depth of 3 feat. r ��L�s� Water rabic depth SEPTIC TANK Type/Mfg capacity iv No.can"..n e. CQ PKG-TREATMENT PLT.❑ r MWh d of D'qv I Distance to neaear War (Q Foundation _ Property Lope_.(> LEACHING LME VY NO. 6 Lagth of Enos 'j^/� Total knglh/ J FILTERBEb 11 Distance to nearest: Wen Foundation---4/ Property Line SEEPAGE PITS Eli-Depth Si.. q 'n Number SUMPS ❑ Distance to nearest: Well ,160 1 Foundation Prapany Una DISPOSAL PONDS Q I hereby certify that I have prepared this appication and that the work will be done in accordance with San Joaquin county ordinances,state laws, and rules and regulauom of the San Joaquin Loral Health District. Home owner or licensed It"A's signature certifies the following: "I certify that in the WOrI sante of the work for which this permit is issued. I shall not anploy any person in such manner as to become subject w workman's umpar cation Laws of California."Contractors hiring or sub cont octirg signature cortifiec the following:"I cer fy that in top performance of the wok for which this permit K issued.I shop employ penults subject to wokman's compensa- tion Taws of Calnomia." The applicant m r for op 'ed ' spections. Complete drawing on reverse side. Signed 7l—u.\/e\�� Title: Date: l / FOR DEPARTMENT USE ONLY Application Acoepted/by �9F,.l DataPR or Gran Inspection by Daleon by E) Additional Canmenta: ❑ Stk 4865781 ❑ Lodi 36&,Wl ❑ Manteca 823.7104 ❑Tracy E3r6385 Applicant- Rawn,an copies toe Fjvirenmamal Health Pon-nn/Services 1601 E Hazelton Ave., P.O. Rex 2008, Stk., CA 95201 iNFO AMOUNT OUE AMOUNT REMIITTED CASH R[-CEIVEO BY DATE PERMIT'NO. n lazannay. .act —7e• qo o��&b �St7^\ 7 a�t�ze