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APPLICATION FOR PERMIT 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 Sen Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and the Rules and Regulations of the Sen Joaquin ' Local Health Oistrict, Job Address /�C3 (,z5�J� . /,,,, / City/& Lot Size PM Owners Name Address -�t�25 �. ;9,Le Picone 2+ V r Contractors Name License No. 11'3 LI-3 \�phcna _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ • -DESTRUCTION ❑ PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO.o, PROP. UNE FOUNDATION AGRICULTURE WELL OTHER WELL n PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS---��-r ❑ Industrial ❑ Opal Bottom ❑ Manteca Dia.of Well Excavation Die.of Well Casing ❑ Domestic!Private ❑ Gravel Peds ❑ Tracy Type of Casing Specifications El Public C Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Easter Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done W Well Destruction ❑ ` Well Diameter Sealing Material (top 501 6 1 m Depth - Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALMTJON ❑ REPAIR/ADDITIONX DESTRUCTION O (No septic system permitted if public sewer is available wi lir,280 feet.) Installation will serve: Residence X Commercial— Other, Number of living units:I- Number of hedlooma �� / t Character of soil to a depth of3 fee i:'��- Dg� , Wats table depth SEPTIC TANK ❑ Type/Mfg +—Cap1tL`ityr ' No.Compartments PKG. TREATMENT PLT. C _ Method of Dill Distance to nearest: Well atlV+ Foundation Property Line / LEACHING LINE I No, & Length of linea Total length/si d FILTER BED ❑ Distance,to nearest: Well Foundation =any Line SEEPAGE PITS •x Depth 5 Size _moi Number ONE SUMPS ❑ Distance to nearest: Wail Foundation Property Una DISPOSAL PONDS ❑ r 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 regulations of the San Joaquin Local Health District. Home owns or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is Issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the foaovving: "1 certify mat in the performance of the work for which this permit is issued,I shall employ Persons subject to workman's compensa- tion laws of California." I The applican m t c I for �9jY71red inspxdons. Complete drawing on reverse side. sip` Signed JL_ •✓ .. Tide: Date: L— FOR DEPARTMENT USE ONLY Application Accepted by �i1 Dab ��• •''`'' Area—0 Pit or Grout Inspection b Date Final Inspection by t n' Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 365-3621 ❑ Manteca 823-7104 ❑ Tracy SWAM Applicant-plenum as copies to: Environmental Health Permit/Service, 1801 E. Hazelton Ave., P.O. Be,2009, Stk., CA 95201 FEE F FO AMOUNT DUE AMOUNT REMITTED CASH RECENED BY DATE PERMIT'NO. EH,3.24 IRW.14/81) �0• oC � �� Sb 9 0 EH tea