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APPLICATION FOR PERMIT /0 .o, A� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6761 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 install the work herein described.This appKeation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wall/pump and the Rules and Regulations of the San Joaquin Local Health District. // LBS?FCtQd Job Address S4044- ��3 G -� Gam,., 99 City ,4- Lot Site b 1,- AC PM Owner's Name P4T767G.- A611C AAA14 Address Phone Contractor. g"J2 G. L4I0077 Address LB S`Al- LJLtJA A/ .4L/E License No.YL Y7 L Phone 6J'3 47 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ - OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FUD. 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. of Well Casing ❑ Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done ` \ Well Destruction ❑ Well Diameter Sealing Material (top 5(Y) J� Depth Filler Material (Below 501 / TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION O (No septic system Permitted if public sewer is lJ� available within 200 feet.) CN Installation will serve: Residence ✓ Commercial_ Other Number of living units:--/— Number of bedrooms 7� i Character of soil to a depth of 3 feet: f%4-42K Water [able depth SEPTIC TANK Cl Type/Mfg .45=Y i a ri.i,C CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines / — /04 Total length/site Ow' -I- FILTER FILTER BED ❑ Distance to nearest: Well ..�S, Foundation 30 Property Line AVO SEEPAGE PITS F3� Depth —.14L'—Sim 3'1 Number SUMPS ❑ Distance to nearest: Well /00 Foundation O r Property Line /00 DISPOSAL PONDS ❑ �O I 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 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 performance 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." Contractor's hiring or subcontracting 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 compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X / '- A Title: (--+ Data: 7—/9 —kZ FOR EPARTMENT USE ONLY i .p Application Accepted by a —' Date �� 1`Q—of" Area O _4. A 4 Pit r Grout Inspection by to Final Inspection by� L e.rA Date L Addi3:3o tional Comments: ❑ Stk 466-6781 ❑ Lodi 39-3821 ❑ Manteca 8237104 ❑Tracy 8354M Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazellon Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EH 132.wEv. A �7b re� EH 1, • O� - 60