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F r " �. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE.; STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED-.,, (Complete in Triplicate) f 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 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. t= Job Address ��— _ t City 4107 Lot Size ^' PM Owner's Name c QW2E- y�` � Address J CQ)W_LW LW5 Phone ./I6,c_ Contractor f /i•i;//YIt X946 -, License No. Phone �.- -TYPE OF WELL/PUMP: jNEW WELL ❑ WELL REPLACEMENT- DESTRUCTION ❑ PUMP INSTALLATION LI SYSTEM fJEPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /SEWER LINE�7S �'� DISPOSAL FLD.J'' PROP. LINE GSL i FOUNDATION AGRICULTURE WELL —'~ OTHER WELL PITS/SUMPS l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC N5 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing P!�lrmestic/Private fPr'[iravel Pack ❑ Tracy Type of Casing �pve !l!S Pal Specifications // ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grour/l � ❑ Irrigation 3L�IQApprox. Depth . B'-@.5stern Surface Seal Installed by I — Repair Work Done EIType of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (NO septic system permitted if public sewevis 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: Water table depth F SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No: & Length of lines Total length/size FILTER BED ❑ -Distance to nearest: Well Foundation Property Line { SEEPAGE PITS ❑ Depth ' Size Number SUMPS ❑ Distance to nearest: x Well Foundation Property Line 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 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 I 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 f r all re red inspections. Complete drawing on reverse side. Signed X Title: 47A Date: OR DEPARTMENT E ONLY Application Accepted by v Date Area Pit or Ir 1t inspection by Date CZ Final Inspection by Date n} Additional Comments: ❑ Stk ' 466-6781 Lodi 369-3621 ❑ Mantecat823-7104 ❑ Tracy 835-6385 Applicant- Return all pies : Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk-, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ; + E11,.13_24�(REV.1/H5) 't' �� C � �-Z7 8(p �b�Z2( eH'14-28 N p [p