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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District far a permit to construct and/or install 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. Job Address ( 6{ City r�c,$.Ak of Size__ PM Q Owner's Name h M 'Q r� I v ddrrfess �j a, M�I1` {Y __ Phom_3�1 `Z, ` Contrac r aSS Address Z 7 8� -z!hf_ �L�, l icense No/ XS Phone/ 7 (((�� TYPE OF WELL/PUMP: NEW WELL 16o WELL REPLACEMENT ❑ DESTRUCTION ❑ jV PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ NII DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS -T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial LPOpen Bottom ❑ Manteca Dia. of Well Excavation litek Dia. of Well Casing 184omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing She-..,L _ Specifications L 1-1 Public ❑ Other --IDeltaDepth of Grout Seal .. Type of Grout (� 1 1 Irrigation —Approx. Depth I I Eastern Surface Seal Installed by B ;► a� Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material iBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer n 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 feat: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O 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 I ! Depth Size Number SUMPS, __ _ti-❑ Distance to nearest Well foundation Property Line DISPOSAL PONDS ❑. I 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 pedormance 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."Comrector's hiring or subcontracting signature cartes the following:"I certify that in the pertormancs 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 all required inspections. Complete drawing on reverse side. Signed x,aim %I—A. -' - -� Tirle: 175 Lb_-, - - Date: FOR DEPARTMENT USE ONLY ^/ Application Accepted by ,ern `'^'27- ! _ _ l p/1 .___ Date 77" r Area / Pit or Grout Inspection by / C/1 Date Al x% � Final Inspection by Date Additional Comments: C/ ❑ Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 873-7104 ❑ Tracy 835.6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 WEE. AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT I]N.lO� . ER liar IREV.�ra5i 7 �1-rX EH 1124 ar+L J