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j, APPLICATION FOR PERMIT / 3AN JOAQUIN LOCAL HEALTH DIST CT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telopho6e (209) 466-6781 PERMIT EXPIRES 1 YEAR_VROM 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 fur sewage or No. 113k62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. AN � � (i - 5-i0-- )61 _ Job Address I/l�1't�i('.LfrG�1 `1'.�OS 1 n71 r 1} �-triP {� y �,ZIrA h I 22 Crit( � Lot Size (-,Awn PM _ Owner's Name J r Zet( �� /Vt l 0.rc��j -,,L Address ��D �J r4VO �� ernall5 (A /' 1 A— Phone Contractorlar(?CC Dt'I))rr1, 4- Address �UQ74' firl'1 lcl lrtL (f / CcrlcCr�rCFl c•+� i tc ti License No.(!�J4<<'J N,-S" Phone(41S)Viso 44,4 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT U DESTRUCTION G PUMP INSTALLATION 0 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 Nq� Jr r l LSC r 111 t;x-t C7 ca O Industrial ❑ Open Bottom ManteDia. of Welt Excavationpia. of Well Casing F1 Domestic/Private Ll Gravel Pack 11 Tracy Type of Casing Specifications 1'1 Public 17, Other I I Dolts DCpih of Grnut Seal Type of Grout _ I I Irrigation ,._—.Aprxox. Dopth I I Eastorn Surface Seal Installed by Repair Work Done U Type of Pump H.P. _ State Work Done _ Well Destruction Cl Well Diameter Scaling Material (top 50') _ Depth Filler Material ( 1I TYPE OF SEPTIC WORK: NEW INSTALLATION I I HLIIAIR/Ap I TItDfJ i I (No septic system permitted it L available within 200 feet.) public sower is `J Installation will serve: Residence_ Commercial—_ Othe�/ 'N Number of living units: Number of bedrooms _ l Character of soil to a depth of 3 feet: Water table depth b SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: well Foundation. Property Line > LEACHING LINE f 1 No. & Length of lines Total length/size FILTER BED U Distance to nearest: Well _. Foundation Property Line_ SEEPAGE PITS I I DepthSire _.. _ Number SUMPS L1 Distance to nearest: Well_, --Foundation_. Property Line _ DISPOSAL PONDS O 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of the San Joaquin Local Heaith Dairict. Homs owner or licensed agent's signature certifies the following; 1 certify that in the performance of the work for which this permit is issued, I shall not emptor 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 fCa California. "I certify that in the performance of the work for which this permit is issued, I shad employ persons subject to workman's compensa-` tion laws of California." The applicannt( � must call for II required inspections. Complete drawing on reverse side. Signed X_',-�_ a • - i�Mc.v.� Title: — M n Date: 2-11 4 A DEPARTMENT USE ONLY Application Accepted by Oars —'�` ' Area Pit or Grout Inspection by Dato Final Inspection by /' 1_ / Data Additional Comments: trot �u ,cC/ 7 C�- •t G�f ,.lid CC}>�� ❑ Stk 488-6781 ❑ Lodl 369-3821 O Manteca eZ1 7104 ❑ Tracy 83513385 "'— Applicant • Return all copies to: Environmental Heahh Permit/Services 1601 E. Hazelton Ave., P.O. Box A", Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C INFO RECEIVED 6Y DATE PERMIT NO. • EH132a(REV,1/n-,r �`C�3 -7/� FH 14.28 —SL3-5.U C /LTJ