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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 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 Distrito. Job Address City -27 /-)Lot Site PM GOt/NTy PivRKS�Y' 9 _3 Phone Owner's Name�Air/r70A13U/.�l .Q£lr4°E1�17tq�Mress GREb/O NL. SFaR7� GOMPI FX Contracts /lwa2eaL.plJ6 W,00 fiLC Lf ddress 2620 WILG/lY Rb License No. -�8 l Phone TYPE OF WELL/PUMP: NEW WELL ❑ _ WELL REPLACEMENT O. 'y-DESTRUCTION O PUMP INSTALLATION)b7 SYSTEM REPAIR O � OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -?7 DISPOSAL DISPOSAL FLD. PROP-LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑OP,, Bottom ❑ Manteca Dia. of Wall Eswvadon Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack O Tracy Type of Cesing_ Specificatrons ,2V Public ❑ Other ❑ Deka Depth of Grout Seal Type of Grout ❑ litigation _Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump svgs H.P. State Work Done Well Destruction ❑. Weil Diameter Sealing Material(top 50") Depth Filler Material I8ektw 501 TYPE OF SEPTIC WORK,.-NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION O (No septic system permitted if public sewn is • �„_ _. �,_ - 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 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ._C4 No. A Length of lines Total length/size FILTER BED O Distance to nearest Well Foundation Property Line J I sufAGE PITS ❑ Depth Sim Number SUMPS O Distance to nearest: Well , Foundation Property Line 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: "1 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."Contractors hiring or subcontracting signature certifiiesthe fonowing:"I cerofy.that in the performance of the work for which this Fermi is issued,I shall employ persons subject to workman's compenss- tion Iews of California." The applicantm �}fo/all i lnapeaions. Complete drawing on rreejvesr Ida. /�/ //917 � Date: S Signed Y� Title: _sL��L=G1" e FOR DEPARTMENT USE ONLY O Application Accepted by• /�✓ Date — Area Pit or Grout In by .Date Final Inspection-by, _ Additional Comments: , ❑ Stk 4666791 ❑ Lodi 3653621 ❑ Manteca B23-7104 ❑ Tracy 835-6385 - I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. BOIL 2009, Stk., CA 96201' FEE AMOUNT DUE AMOUNT REMITTED CA9R RECEIVED BY DATE PERMIT NO. INFO EH 13N lacy. /951 exon j—// 7 bh's/CCS 85 \'� S �Ee 14tH /�