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iAPPLICATION FOR PERMIT i r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2091466-6781 i �. PERMIT EXPIRES 1 YEAR FROM 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 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 56o6 P";f;c, Job Address IA . Carnoy- 1 ��y� �LAAOOJI (Ci//t1y 5roLot Size - PM Owner's Name 11fn 0y% J l l Address Z -75 Af C&I AV*- r�nU� CY'CP.I� � `1`P59(� ��WW" r ��7y Phone 4.5- 76-7 h Contractor� -�(eu�7i4_d Qr Y.j13YY1�r�dress $ G JI/ License No.4 69 Phone 't?J TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER fg Mor�1}Or1hq LLPJ1 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 SPECIFICATION5 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation— Dia:of Well Casing 2v ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public /❑/ ^^OPer ❑ Delta Depth of Grout Seal r Type of karout 6 ❑ Irrigation Ip}J_gpprox. Depth O Eastern Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump H.P. pState Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 W�� Depth Filler Material (Below 509 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 2(10 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 Capacity No. Compartments. PKG. TREATMENT PLT.❑ Method of Disposal _ Distance to nearest: Well Foundation Property Line- LEACHING LINE ❑ 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: 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 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 mu all all four r uire tions./Complete drawing on reverse side. P Signed X ✓Lt , 'V., rga: Date: F R EP MENT USE ONLY Application Accepted by Date - - Z'7L-- Pit or Grout Ins t b Date 3-S6 FinalInspection by Date Additional Com a: ❑ Stk 466-6781 ❑ Lodi 369-3621, ❑ Manteca 823-7104 ❑ Tracy _ - Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED aV DATE PERMIT'NO. EM 11211REV.v x sl EH 1<24 3s0-o 11311, Ad r7 zJZ-Pit 8!0-228