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APPLICATION FOR PERMIT SA JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 5 \ v Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein(� cribed. TP4'.abplication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and*j Ibnkipns of(the San Joaquin Local Health District. (oL f64Jj( PVA. Job Address SCity Lot Size PM �� N- (Alt , F,1 slat 650 Q.�� Owner's Name �I] 1�—. _ Address wp �1 -(�� . 94644 /Phone 5__ e+ 115 Contractor ddress /u� ��License No. X16 Phon 1 TYPE OF WELL/PUMP: — NEW WELL DK WELL REPLACEMENT ❑ DESTRUCTION ❑ f2 DISTANCE PUMP INSTALLATION El1 SYSTEM REPAIR ❑ OTHER 1(a 0 6+r)rl1,8 f 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing,711r Specifications,� ✓i �X xO�ther F1 Delta Depth of Grout Seal Ay _ T(pe of Grouthe"y.�} 2 0<IrripeYpnll�l , Approx. Depth 1 I Eastern Surface Seal Installed by M Repair Work Done , (J Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 O TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 1No 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: Water table depth 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r 'i LEACHING LINE Ll No. 8 Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS ; I I Depth Size _ Number SUMPS LI Distance to nearest: 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 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting 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 Califprpla." The applicant musy call to II required i spections. Complete drawing on reverse side. ,fes q Q Signed �'� Title: yO LOGEOL O<!S i7" Date: ret c "G" (' orPION pR DEPARTMENT USE ONLY Application Accepted by Date /Y VY Area Pit or Grout Inspection by [} Date Final Inspection by Date //�l Additional Comments: _j r f j o1 4 Li.. 1J, l ac&L t .� CVQW. Qc.g . !.Nki ❑ Stk 466-6761 ❑ Lodi 369-3620 Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED eY DATE PERMIT'NO. S EH 13-24IREV.I/x51 •�) � .11 1 4. 1-/ 'r