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a 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 tical Health District. / �?,-iof( 27• 6 A01c Job Address ? �,� Ly 'd City_ Lot Size 'J� L PM )wner's Name )2z.z L�J— (ya Address ;`aoify ' r��6 Phone Contractor Address Sf' C,46n &11.141No.,3p-i'7.4/ Phone3 ✓>3 -YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 7 Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications _'I Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation -_Approx. Depth I I Eastern Surface Seal Installed by _ 9epair Work Done ❑ Type of Pump H.P. State Work Done _ J Veil Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: ( Number otJ; rooms e Character of soil to a depth of 3 feet: O, Water table depth 0 iEPTIC TANK ❑ Type/Mfg Capacity No. Compartments "RKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ^ BEACHING LINE Ml--No. 8 Length of lines Total length/size 5 0 " / FILTER BED El Distance Distance to nearest: Well f0 Foundation �, Property Line iEEPAGE PITS W Depth�� Size Number r UMPS LlDistance to nearest: Well/3o Foundation Property Line DISPOSAL PONDS ❑ 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 _ mules 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 sub-contracting signature :ertifles 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 ion laws of California." The applicant mus[ call for al required inspections. Complete drawing on r arse side. iigned X Title: — Dale: �Q j FOR DEPARTMENT USE ONLY Applipaiion Accepted by Date Are rt/ �� ;�� or'l0rout Inspection by o� Final Inspection by ��`/n Date/� Additional Comments: c) ll�nfis I'eL - _ 7 (� -� ) 00 7 Stk 466-6761 0 Lodi 359-3621 ❑ Manteca 623.7104 ❑ Tracy 835-6385 1pplicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., C 95201FEE INFO AMOUNT DUE AMOUNT REMITTED t12H RECEIVED BY DATE/- PERMIT NO. EHti 24I11EV.'/x5) EH 14-A