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Y APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON; CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR 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 District. J ' Job Address tl b / �L11"{/ 2 City L�' Lot Size ode� - - PM Owner's Name ?C T _ Address >s S`U C Arfx t� / Z 4& 1 j -f.1141 Phone Contractor 61� r.-Yi'd 5p7Et r_-_Address)` ,-AI AAA 4 t• Liense.No��s'N3�/ phone 60 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION O_ - _SYSTEM REPAIR ❑ _ OTHER ❑ r —DISTANCETO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL TLD. �pROP'LINE�_4� •-!" 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 'INT ENDED USE TYPE OF WELL PROBLEM AR EA CONSTRUCTION SPECIFICATIONS ❑ Industdal 17 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing -❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications PI Public i LT Other F1 Delta Depth of Grout Seal r ) rf Type of Grout_ I��Irrigaticn4 - —Approx. Depth I I Eastern Surface Seal Installed by RePaif Work Done ❑ Type of Pump H.P. State,Work Done Well Destruction' ❑ Well Diameter Sealing Material (top 501 i ( Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence✓f Commercial— Other Number of living units: --I— Number of bedrooms Characterr of soil to a depth of 3 feet: ^0 N .. 3 plVdlu SEPTIC TANK Llf Type/Mfg 'G DAiWater cAG� pcy �Z" No. Comilia rtlent s -7- PKG. TREATMENT PLT.❑ -'f- Method of Disposal Distance to nearest: Well/BO f'F Foundation t p Property Line g0�� TEACHING LINE L9" No. &Length of lines .3- y0 Total length/size - y1 FILTER BED '❑ Distance to nearest: Well D v'� t ` Foundation Property Lina 'SEEPAGEPITS IEfDepth ..1's Size_,�/�' "r yrNumber. . \ .`SUMPS . L1Distance to nearest: Well Foundation%�0' E t 1"properry.,Lina SW DISPOSAL PONDS ❑ I hereby codify that I have prepared this application and that the work will be done m accordance with San Joaqu'rrl,county ordinances, state Wws, and rules and regulations of the San Joaquin Local Health District:" Home owner or licensed agent's signature c rnifiep the.folloviing:J.Fertify_that,in.the perfomlance of the-work far-which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Celiforma.'s CdnoaetoCs hiring or subcontracting signatu, canities the following:"1 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 Califomie." - -d•t; �., ,-r The applicant must call for all required inspections. Complete drawing on reverse side. 'A Signed X p Al t Iw _ _ Title: Date: 414 '- —'--- FORZ' Z USEY -Application Accepted by ;D'a©Z%;/ i4 Area / — cJ PI Grout lnspactlo ate2/ on -_T '• ?N/•�+A� ��n J Date Additional Comments: ❑ Stk 488.678[ ❑ Lodi 31343821 ❑ Manteca,82&7104 ❑Tracy 935-6385 -' Applium- Return all copres to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED DASH RECEIVED BY DATE PERMI7'NO. EH 14th