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APPLICATION FOR PERMIT -� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE iTON AVE., STOCKTON, CA Telephone (209) 466-6781 P PERMIT EXPIRES 1 YEAR FROM DATE iSSUED (Complete in Triplicate) ti Application is nereby made to the Sat Joagt,in Local Health District for a pemtit to construct and/or install the work herein described.Tt9s appilicartion is made in compliance with San Joaquin Counrr OrdinRnce 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 _ City "'irCle L ) Lot Size PM Ownar's Name ,17 !/7 r 1 'it7J_ Address X990 V P2(111, Phone-`L Contractor :.�y c Ji7c. Address .'!. i L•r License No. 4x`'90/ Phone�� 7 TYPE OF WELL/PUMP, NEW WELL Cl WELL 1`%2PLACEMENT ❑ DESTRUCTION ❑ O PUMP INSTALLATION Cl SYSTEM REPAIR ❑ OTHER O DISTANCE TO:VFARE3T: SEPTIC TANK SEWER LINES __ DISPOSAL FLD. PROP. LINE FOUNDATION _ AGRICULTURE WELL OTHEF WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �.�. ❑ Industrial ❑Open Bottom ❑ Manteca Dia.of Well Excavation Dia.of Well Casing v Domestic'Priv,;te ❑ Gravel Pack ❑Tracy Type of Casing Specifications 0 Public C Other C Delta Depth of Grout Seal Type eA Grout_ r C Irrigation _—Appror.. Depth L7 Eastern Surface Seal Installed by Repair Work Done C Type of Pump _ H.P._ ;tate Work Done Wei' Destruction C Well Diameter Sealing Material(top 601 f Depth Filler Material(Below 50'1 --__--_— TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIH/ADDITION❑ DESTRUCTION a (Nn septic system permitted if public sewer a J availahle within 200 faet.) Installation will serve: Residence_ Commercial_iL Other Number of living units:_— Number of budrooms. _ y Character of soil to a depth of 3 feet: Water table depth n SEPTIC TANK ❑ Type/Mfg (e4)2Capacity_ t!No. Compirtments PKG. 7 REATMENT PLT. ❑ J Method of Disposal _ D:,tance to nearest: Well Foundation <S"C Property Line_ LEA;:HING LINE. ffY No. &Length of lines _ e:7 f !'%e' y_=t.Total length/size 3 F:t_TER aED E Distance to nearest: Well oundation Property Line SEEPAGE PITS Depth _ Size ___—__ Number SUMPS Distance to nearest: Well Foundation —_. Property Line DISPOSAL POND, C. I hereby certify that I have prepared this apolication and that the work will be done in accorteance with San Joaquin county ordinances,state laws,and rules and tegu:ations of the San Joaquin Local Health District. 5 Home •/vner ui licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is Issued,I shall not employ any pemon in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature 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 cumpenso- tion laws of California." The applicant�musst cill for all rrquired inspections. Complete drawing on reverse side. Signed X'L1 —..�- -.—�_�1!' Title:_ /:�' / e'. i _ Da?e: ��ZyrC, FOR DEPARTMENT USE ONLY Application AcceptaJ b, l�1 !' Date Area 0 21 C/ Pit or Grout Inspection by L� _ `— — Date _/4 Finial Inspection by r � L-j—n- Date I AdditionalCrmman:s: NO D�IVING [7Ufe_ n ��✓N �n'Ar. 44 6 — ,.; Stk C66f7&1 ❑i Lodi 369-3621 C Mentons 823-7104 ❑Tracy 935 0 "` C / Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i (� � FEE AMOUNT DUE AMOUNT REMITTED ZA�1'f RECEIVED BY DATE PERMIT'NO. . EH 13 241RE`J. INFO 7'�•. UC j�-a�1.7 r /7.'Y7J'�� -� Z/S EH is 26