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V APPLICATION FOR PERMIT ✓I ;�. ,,.•rte `'�� , s �r� � �v�'�' � N LOCAL' SAN JOAQUIHEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 f 1 ERMIT EXPIRES '1 YEAR FROM DATE ISSUED ' yl- �• (Complete in Triplicate) - AppGeation' heretsy ada to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made In com liance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San J oaquin JLocal Health District. . d� Sn 1�1 D ! �L Z` " Job Address �;t Q City 3L_2�(C_lu, _4L�Lot Size r PM t.. ; :' -�i his• .. •' 414 t. .., o't ' .:1.. . r...-, :. .t � ...... Owner's Name �/^G/�S eJ I'r &WAI Address yap �D. Q t {ley:t4l-_JR Phone ContractorAddress _ - License No. Phone TYPE OF WELL/PUMP: - NEW WELL G -WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATIO /- SYSTEM REPAIR G OTHER 171 DISTANCE TO NEAREST: SEPTIC TANK Et e_ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION!i AGRICULTURE WELL OTHER WELL. ._ PIIS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom C Manteca Dia- of Well Excavation Die.'of Well Casing ❑ Domestic/Private C� Gravel Pack C Tracy Type of Casing - Specifications ❑ Public C Other L Delta Depth of Grout Seal _ Type of Grout I ❑Irrigation —Approx. Depth G Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump ej H.P. State Work Done Well Destruction 171Well Diameter Seating Material Itop 501 _ Depth___ Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION C. REPAIR/ADDITION LJ DESTRUCTION .. (No septic system permitted if public sewer is �r 1 ailabie within 200 feet.) Ui Installation will serve: Residence_'Commercial_ Other Number of living units: Number of bedrooms ( i Character of soil to a depth of 3 feet: _ - Water table depth . SEPTIC TANK G Type/Mfg r"" '_Capacity No. Coripartments U� f PKG. TREATMENT PLT.❑ ,# . Method of Disposal 1 Distance to�neartsi:'� Well Foundation Property Line LEACHING LINE ] No. & Length of limes Total length/size--- FILTER BED ❑ Distance to nearest: Well I Foundation I. ._ Property Line _ SEEPAGE PITS ❑ Depth .Size f Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 71I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cnnty ordinances, state laws, and rules 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 J certifies the following:"I certify that in the performance of the work for which this permit is issued,I shell employ persons subject to workman's compensa- tion ompensation laws of Cal'rfomia." p The app7�= r�'`�qui" inspections. Complete drawing on reverse side. Signed .a7 - 62 Title: r`� _/fh /lam Date: ,___._ FOR DEPARTMENT USE ONLY 12 - Application Accepted by Date Area L Pit or Grout Inspection Final Inspection by-- by Date Additional Comments: l t c��{ w O�� i yr ❑ Stk 466-6781 O Lodi 369.3621 ❑ Vanteca 823-7104 ❑ Tracy 835-6380- Return all copies to: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 , FEE INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY !.DATE PERMIT NO. EH 1344(8 EV_5;651 EH 14-28 �♦ �� Q fd� ! �...��T� ��Si`p