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I APPLICATION FOR PERMIT AN JOAQUIN LOCAL HEALTH DISTF 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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 thea aed, s of the San Joaquin ,..., x Local Health District. Job Address 3� W. ( ( STIQ.CCT City—TO— C,� .VLot Size ` PM PV-0J E C Owner's Name L`l�Z� �IF.`CS Address r /? ? P �� tc)C.L_t. 6.iJ�V�t2 SP ��lVt►�Otvt�t�cV7�1` ; tS'Cicwlo 97/6 1.,Noc,,7Av Ilt ' ei� et& �:Tr 31a- :Rr_.Sj73 1?-W+'_H0 h Contractor (�S-r oZM AAddress 3F�33!:r, Licenf�;FT5r�q_r' Ph;hi 1? - 36--:70 6- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DEB `GTibW!n21- J PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER HLfb0?o&_)c_H DISTANCE TO NEAREST: SEPTIC TANK > SEWER LINES 7 �;'r2 DISPOSAL FLD.> `-�O PROP. LINE /4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation !O r Dia. of Well Casing �rvE ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications * Public rl Other n Delta Depth of Grout Seal �O N Type of Grout I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by 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 I REPAIR/ADDITION I I DESTRUCTION l I (No 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: Wertab depSEPTIC TANK ❑ Type/Mfg Capacity Nos l PKG. TREATMENT PLT. ❑ Method of Disposa 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 I I Depth Size Number SUMPS Ll 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."Contractors hiring or sub-contracting signature 1 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 for all required inspections. Complete drawing on reverse side. 1 Signed X Title: �ct�c-bbl ST Date: FO,= H Lei FOR�X)OAARbMEW USE ONLY Application Accepted by Date — A r- Pit or Grout Inspection byDc•_��5".Final Inspection by Date�� 25 r Additional Comments: ❑ Stk 466-6781 ❑locli 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 952017FEE INFO AMOUNT DUE AMOUNT REMITTED CK CA/SH RECEIVED BY DATE PERMIT' NNO�. . EH 13-24 IREV.I/x 5) •O� 6 ^�.—� ./ �/ ! //X EH 14-2e 111 U