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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 instaff the work herein described. This 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. y� ,y / // �,,, .� ` Job Address /� 3e2l_ . �yf /T/V �f/ City //�,--Lot Size-=L^�Lr"C_S� PM Owner's Name �6NA) C/ �L.IC_ I s - 777 61W714! Phone Contractor Address r ✓� License No. Phone thZ� L TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ LINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications L ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_. I I litigation —Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction. ❑ Well Diameter Sealing Material (top 50') Depth Filter Material (Below 50'1 - TYPE OF SEPTIC WORK: NEW INSTALLATION 7�14EPAIR/ADDITION t I DESTRUCTION I I (No septic systerrj;permittad if public sewer is available within 200 fe�Lt Installation will serve: Residence_XCommercial_ Other � Number of living units: t Number of bedrooms '�? !(� Character of soil to a depth of 3 feet: s Water table depth SEPTIC TANK ❑ Type/Mfg 'f Capacity /22 No. Compartments PKG. TREATMENT PLT. ❑ 01 Method of Disposal �O Distance to nearest: Well Foundation 62— Property Line L LEACHING LINE ❑ No. & Length of lines ��,� Total length/size I FLTEfl BED ❑ Distance to nearest Well—.� Foundation Property Line I I l �J�VJJ SEEPAGE PITS 11 Depth z4ro, Size Nu bar SUMPS ❑ Distance to nearest: Well oundation / Property Line DISPOSAL PONDS ❑ i 1 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 1` rules and regulations of the San Joaquin Local Health Dr'Strict. 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, 1 shall not employ any person in such manner-as to become subject to workman's compensation taws of California." Con actor's hiring or sub-contracting signature L certifies the following: "I certify that 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." - The applicant must call for aft required Inspections. Complete drawing on reverse side. Signed X—, �(r.5f __ Title: X97 "t-��l „y. Date: v7 P._ DEPARTMENT USE ONLY Application Accepted by -�--v- Si,rfl-0 f 014 Date Area L ` Pit or Grout Inspection by Date Final Inspection b� Data Additional Comments: L ❑ s" 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT �DDU-E� AMOyU''NT R��EppM��ITTED CK[} RECEIVED BY j DATE(�.t PfEgRMIYNO. M24 -EH IC26 tRtN.IIRa) EH IDI �V