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lti • APPLICATION FOR PERMIT • F_ SAN JOAQUIN LOCAL HEALTH DISTRICT " 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SA)" QL (Complete in Triplicate) Eq� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.TMs 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. `I'�// m-Z/ ��jj Job Address�t6)-,°�'fi1°"" Roberts AVelDcak 8IV-CL City R /14/I f�Lot Size l/-- PM -- _ Owner's Name `�f Address25q N• fN �/na- t"'t�• ,\/P Phone 19 59q -2 /e 2 j� l�rp,.�It51 Contractor r I f r 'll/l n Address �'^-�C �/n" 014 License No. 2 - Ge'S Ph1M1a z8 / TYPE OF WELL/PUMP: N W WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER lY)Cr/i 'n9 V✓elI DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES >.50 DISPOSAL FLO. A/q PROP. LINE >SO FOUNDATIONnfA AGRICULTURE WELL150" OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial �❑y Open Bottom ❑ Manteca Dia. of Well Excavation �C-/n Dia. of Well Casing �a S�/nC ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing PVG Specifications r•1 Public 71Other n Delta Depth of Grout Seal SSC 1 C Tyre of Grout 2IrRir7 r�Ket �lrllincY I I Irrigation 220'/& Approx. Depth I I Eastern Surface Seal Installed - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available w.thin 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT.❑ Method o' Disposal Distance to nearest: Well Foundation Property Lina EACHING LINE ❑ No. & Length of lines Total length/size- ---.--FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenity trial I have prepared this application and that the work will be done in accordance with San Joaquin•%Ounry ordinances, state taws, and ruins and regulations of the San Joaquin Local Health Dibtrict. - Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for wh`ch this permit is Lssued, I shall not employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's miring or sub-contracting signature certifies the following:"1 certify that in the performance of the work for which this permit is issued, I shall employ person subject to w.lrkman's compensa- tion laws of California." _ The applicants mustcallfor all reguiu�ireyd9 inspections. Complete drawing on reverse side. Signed x (f. Title:�DA�/ 5� /U/r✓eDate: ��J 22 �� FOR DEPARTMENT USE ONLY Ap6ication Accepted boty U4kQ - Date 1 I ' tl Area Pit or Grout Inspection Date yZ Final Inspection by ` ' Date i Additional Comments: _ ❑ Stk 4666781 ❑ Lodi 361-3621 ❑ Manteca 8234104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Fermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 (I) A-P�.Qicr nt 7s N - veq Co, aurae.- C+ 2, �,t� FEE AMOUNT DUE AMOUN REMITTED CK 0 CASH RECEIVED BY DATE PERMIT'NO. ]� - R— DATE . EH 13 24(REV.riMei�X I OV �c l2 6 3l urJ •- EN IC29