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i r 1 r F a APPLICATION FOR PERMIT v SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-Ml 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 end/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1882 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Q"�77� / ��fl Job Address f ti °' " k/ _Ae He-n " tom" City jjll - Lot Size PM 3 p 2 a�ltr d q // Owner's Name __.�-'� Y✓L Address (7 / PfbaneY�� O- 'S Contractor Address ^ �` License No. Phone Z`Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTDESTRUCTION ❑ PUMP INSTAL TIDN ❑ SYSTEM REPAIR ❑ fOTTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD.J��Z PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA TIVP [/ ❑Industrial ❑Open Bottom ❑ Manteca Dia.of Well Excave n Din.of Well Casing/: ' omestic/Private ri�Gravel Pack �i'racy Type of Casin Specifications 6v' r ❑ Public rr❑�`Oth/.e^r EI Delta Depth of Gram Seal _ Type of Grout �H O Irrigation, PfeX. Depth ❑ Eastern Surface Seal Installed by -04= Repair Work Done ❑ Type of Pump H.P. State Work Dona Q Well Destruction ❑ Well Diameter Sealing Material(top 50') O Depth Filler Material(Below ST) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation will some: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soi 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: Well Foundation Property Line LEACHING LINE ❑ No. &Length of lines _ Total length/size FILTER BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ oistanca to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance With San Joaquin county ordinances,state laws, and rules and regutellone of the San Joaquin Local Health District. Home owner or Licensed agent'e signature certifies the following: "I certify that in the performance of the work for which this permit h'ssue 1,I shall not employ any parson In such manner ea to become subject to workman's compensation laws of California,"Contractor's hiring or sub-contracting signature corcfies the following:"1 certify that In the performance of the work for which this permit is Issued,1.hell employ pi roene.vbjact to workman's eomlwnse- don laws of California." The appGcan ca�ll for all !red inspections. Complete drawing onrse odye. Signed X Tide: ■"1�/J - Date: �Qc r F EPA ENT USE ONLY G Application Accepted by "l��-� Q� Data CE — 6 Area y Ph or,!fro Inspection b1t� Date //Fina�l Inspection by Dam Additional Comments: � �L�� N`! T� ❑Stk 466441 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 8354MS Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazetcn Ave., P.O. Bax 2009,Stk.,CA 86201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT NO. . EH r3.0 late.iia W FH ism C.