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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA. Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the SaniJoaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquiri County Ordinance No. 549 for sewage-or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 5L P ZI Ro lJ City &9.441 T��Lot Size PM Owner's Name "Tl M . ��(,z V b Address T-65 C:P7T �p'2i' Phone ��F. r 4 E• Contractor_ IL. FL Addressd 1�9 A//%rS,t4 License Noo�7�y2 Phone_ _�— f. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - ❑ Industrial O Open Bottom ❑ Manteca Dia-,of Well Excavation Dia. of Well Casing ❑ Domestic/Private CI Gravel Pack ❑ Tracy Type of Casing Specifications tB 1'1 Public Cl Other t ❑ Delta Depth of Grout Seal Type of Grout 1 I 1 Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. p' State Work Done_ r f Well Destruction ❑ Well Diameter Sealing Material (top 501 _ ^° Depth - Filler Material l8elow 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION DESTRUCTION f I (No septic system permitted if public sewer 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: / L r' Water [able depth + SEPTIC TANK C1Type/Mfg ._.._DL /' Capacity rr No. Compartments E PKG. TREATMENT PLT: ❑ # b �r Method of Disposal 4" Distance to nearest: WQII 21 Foundation cW' Property Line LEACHING LINE. � ; ,q No. _Lenglh,of,lines"`' Total length/size & � ^4s� i. -:..•. FILTER BED tbnearest: Well Foundation�a7�r�""'property L'ihe ,�_... ; SEEPAGE PITS 11 Depth Size 1 Number_ 1, SUMPS fl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ w _ 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.•.-a -ar Home owner or licinsed agent's signature certifies the following: "I certify that in the performative of the work for which this permit is issued, I shall not employ any person4 such manner as to become subject to workman's compensation laws of California."Contraetbes 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 compansa- tion laws of California." The applicant must call to all required ins tions. Complete drawing on reverse side': Signed X_. -6—�7 ; L' Title: Data: — � DEPARTMENT USE ONLY ' Application Accepted by ' A I Date r Of Area Pi[or Grout Inspection by i 1 r r . Date Final Inspection by -+�'� Date Additional Comments: � ❑ Stk 466-6781 ❑ Lodi`;i369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copiestto: Environmental Health Permit%Seririces 1601 E.'Hazelton Avel, 0.0- Box 2009,.:Stk' CA 95201 I ' IN O AMOUNT DUE �.AMOUNT,REMITTED CASH a- RECEIVEfDBY_,w __DATE rM,_ -KP.ERMITNO.--•77-1 ..: - . .-• ♦:EH 13-241REV.1/45I I� �yT E 14.26 EH Ul