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1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6761 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED (Complete in Triplicate) =1. . Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.TNs 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 Job Address I �I X66 -... -5 ere,Ll- "nyile,- +2.n 'C,�, n .` Lot Sim •' 'dr. .QPM / Owners Name`s L z-f I"']I Address Cc f-K ei' .Phone 4 —547 Contractor AddressPE Ign�G��}.4 License No. 7�-5 Phone TYPE OF WELL/PUMP: .'.NEW WELL ❑ WELL REPLACEMENT Cl,;. '! �'DESTRIJCMON Li; PUMP.INSTALUrT•ION-0-� �* --SYSTEM REPAIR❑ - ^'"^'�1: •-OTHER O" DISTANCE TO NEAREST: SEPTIC TANK $EWER LINES- DISPOSAL FLO. PROP. LINE 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..ef-WeIFCasing.,- ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public - ❑ Other ❑ Delta Depth of Grout Seal 1 T " C Type of:Grout- O Irrigation a _Appmx..Depth ❑Eastern Surface Seal Installed by ' 1"'v ->• = 1ON i Repair Work Done .❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop:50'1 Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION q (No septic system permitted if public sewer is / ^( _F available within 200 feet.) Instaketion will serve: Residence.(,G• Commercial_ OtherR:•.�_ 1 Number of Wing units:_j__ Number of bedrooms�J?--- ? Tr ->• .4• I i Character of soil to a depth of 3 feet: }_sp�j.-_ I.eS-N7 !�-"-11�T"� Water table depth n ,l SEPTIC TANK ❑ Type/Mfg Q•d. / � f� t 'Capaa1ty � O . No. Compartments VVV PKG.TREATMENT PLL❑ 1� Method of Disposal_ isposal ) :.Distance to nearest: Well' Foundatiorr�0i Property Line LEACHING LINE v 121*�No:'&Length of lines ^�• y.�� I 7 atal length/size - -- _-- 1 FILTER BED �,p Distance to nearest; Weil-J-br— Foundation }' Y 'property Lire 'T ''+ r !�� ay SEEPAGE PITS ❑ Depth .kd Sim _ (.� �. .}••i irylimyer - , --. '-. _.. SUMPS, 0 Distance to-neareac Well�� Foundation�_ Property Line DISPOSAL PONDS ❑ I I hereby cannily that 1 have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws. and `t rules and regulations of the San Joaquin Local Health District, ( _ 1 Home owner or licensed agem's signature cantfss the folknving: "I certify that in the performance of the work for which this permit is issued, 1 shell not employ any person in such manner as to become sub' ct to workman's compensation h this permit laves ss Caled,I shall ploy Contractor's hiring or club-contracting signature certifies the following! ,' certify that in the performance of the work for which this permit is issued,I shell empty parsons suDjett to workman's colnpensa- tion lawn of California-" f _ _ , The applicant must call for all rad inspections. Complete drawing on . � �roe side. Signed X Title: ' Date: c } -FO DEPART6j3ENT USE ONLY Application Accepted by 1 . " Date Area o6 Ph or Grout Inspection by - - D { II- Final Inspection DY Daoa-7- j"�d� Additional Commends; ❑ Stk 488.6781 . .. ❑Lodi 369.3821, ❑Manteca M7104 } ❑ Tracy 63544 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2DO9, Stk., CA 85201 ., FEE .r AMOUNT?DUE• AMOUNT AEMfTTED CK INFO _ OASH RECEIVED BY DATE PER .'�EN iia{iREV.I/Ari 8`11476 •O b t /5 �tp 9