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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT { 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209)466-6781 r , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1 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 l made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1852 for well/pump and the Rules and Regulations of the San Joaquin 4 Local Health District. Job Address .�c� GL !'d.^.�12-d'! \�df. City v't "�f Lot Siizee.'��-.fc" Ult'LCA; PM M Owners Name �� -'r'r )//t'- /�''CLC'.G�/M Address / ' �� Ct �f/`C. ( —2c/ -L- /�l.��L-r-1� hone �Z x c Address � TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [3 Industrial 0 Open Bottom ❑Manteca Pia.of Well Excavation D]a.of Well Casing i ❑Domestic!Private ❑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 C1 Type of Pump H.A. State Work Dane.� rp I1�7. Well Destruction I--] Well Diameter Sealing Material{top 60'} r V y Depth Filler Material(Below 501 U� TYPE OF SEPTIC WORK: NEW INSTALLATION❑QFPAIRYADDITION - DESTRUCTION❑ INo septic system permitted if public sewer is N available within 200 feet.) Installation will serve: Residence_1�Commercial ther "L Number of living units:__,l Number of ibedm.,,s ,f Character of soil to a depth of 3 feet: _____f Water table depth SEPTIC TANK 0 Type/Mfg Capacity No.Compartments } PKG.TREATMENT PLT.❑ - Method of Disposal $ Distance to nearest: Well Foundation Property Line LEACHING LINE Lr No.&Length of lines / — h((//Q .Total length/size (D K 2— FILTER FILTER BED ❑ Distance to nearest: Welles Foundation/ t T Property Line 3 v SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest. Well Foundation Property Line f DISPOSAL PONDS ❑ [ 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 k rules and regulations of the San Joaquin Local Health District. f 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 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 I�requir��dyinspections.Complete drawing on reverse)side'e ,/ Signed X -- `� �' Title: �'• J Date: �U9LC 7:7- FOR DEPARTMENT US ONLY Fj Application Accepted by _ t�[-4'/'�f 4 Date ,e��^//'� Area 's Pit or Grout Inspection by .� Date Final Inspection by:777 "- �l f Date J Addhianal Comments: ( ❑Stk 466-6781 ❑Lodi 30-3621 O Manteca 8237104 ❑Tracy 635-Fi385 Applicant-Return all copies to:Environmental Health Permit/Services 1601 E.Hazelton Ave.,P.D.Box 2009,Stk.,CA 95201 I INFO I AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. I I Li i 13111aEV.rind � I Fl— F! I1]C f EH 11.2e � 1 �o /t0 O� F 1 3 _ _ 'IIS M _a I �I