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APPLICATION FOR PERMIT -�C'iri•" .n SAN JOAQUIN LOCAL HEALTH DISTRICT 17�''`` 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ITpL "iE LTH V ROMIE' S Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the �J application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ru egulations of the San Joaquin Local Health District. f1 Job Address ��r � --�p�7 '� i� )W City :i:T' Lot Size PM Owner's Name /'r �X� J /JL'— AddressPhone Contractor N Address 521-a�d 411 G e_X .P/'License No.-�¢- cE._Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION j PRr,0.<,oWXA}�'6TEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE — Q 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 A%omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth pEEastern Surface Seal Installed by s�� Repair Work Done ❑ Type of Pump --�GIIi H.P. State Work Done L�>L�C O6fEG'7i/.1�SO,B Well Destruction ❑ Well Diameter Sealing Material Itop 50') 7.V.T.9L� n A.VF Depth Filler Material (Below 51 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 living units:_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING UNE ❑ No. 14 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well -Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 laws of California."Contractoes hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant mut all all r�inspections. Complete drawing on reverse ide. / Signed X � rw, i1J7�J�C1.Cs"% Title: 'S /��•%?7 .�r1!`JZ_ Date: �A7.W� FOR DEPARTMENT USE ONLY 45273 Application Accepted b _ Datey/�' Aren Pit or Grout Inspection Date Final Inspection by r Additional Comments: ❑ SIX 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 8354385 Applicant - Return all copies to: Environmental Health Per nit/Services 1601 E. Hazehan Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED eV DATE PERMIT NO. INFO ' •EN,a-Z4 III I,asi