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sal bt—f3 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA �flll Telephone (209) 4668781 ,. PERMIT EXPIRES.1 YEAR FROM DATE ISSUED (Complete in Triplicate) wTAI HEALTH ENu1ROME. Application is hereby made ro the San Joaquin Local Health District for a permit ro construct and/or instep the work hereinFd6fi;hW f/71�1gn 4 made in compliance with San Joaquin County Ordinance No.548 for sewage or No. 18M for well/pump and the Rules and Regujatios of the San Joaquin Local Health District. h - Job Address7J-L. 1`^'�"' City/_LQp>�Lot Size y PM Owners Name n' 'I ,,M/�•� Address��O A /�'�1+//' 9 Phone 476 -�e'� Contractor 1�-`^'•^'/I Address�T6 A Cie.-4 License No�rO"Y-'7_3 Phore 6G"9G ad TYPE OF WELL/PUMP: NEW WELL ❑ ` WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION W SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS p� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y,1 ❑ Industrial O Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing (id Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications O Public ❑ Other ❑ Delta Depth of Grout Seal r Type of Grout e ❑ Irrigation ----==�Approx:-Depth/--O-E�a�cterr.�:-•�Surfaca-SmI Installed byi''-�"-�— ^ `\\ Repair Work Done $, Type of Pump & tiv— H.P. I State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 - TYPE OF SEPTIC WORK: NEW INSTALLATION"O REPAIR/ADDITION ❑ DESTRUCTION O (No septic system permitted B public sewer is available wlthin 200 feet.) Installation will serve: Residence Comriercial_ Other 'Number of living uric: — Number of bedrooms Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Oisposal Distance to nearest: Well ' Foundation Property Lina e LEACHING LINE `❑ No. & Length of lines Total length/size FILTER BED C'-Distance to nearest: Well Foundation Property Line l SEEPAGE PITS ❑ Depth , `• Size Number SUMPS ❑ Distance to nearest: -'Well Foundation Property Line DISPOSAL PONDS O I hereby certify that 1 have prepared this application and that the work will-be done in axordance 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 cartlfies the following: "I certify that in the performance of the work for which this permit is issued, I shat'not employ any person in such mannerist to become subject to workman's compensation laws,of•Cslifomla."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I snall.employ persons subject to workman's compensa- tion laws of California." The applicant m/yet call for all qu/p�d inspections Complete drawing o-p�yrev_eQrse-side. Signed X- 7( V lii^�-� /..Gs'rda: 0�"'V ✓ Date:` FOR DEPARTMENT USE ONLY Application Accepted by �'� .� Date Area to n Ph or Grout Inspection by Date Date . Additional Comments: , ❑ Stk 4668781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354386 Applicant-Return all copies to: Environmental Health Permit/ServiM4001-E. Hazehon Ave., P.O. Box 2009, Stk., CA 96201 FEEAMOUNT DUE NT REMITTED K RECEIVED BY DATE PERMIT'NO. INFO CASH •EM 1 a.24(AM.1/66) EM 1426