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r a T 1 APPLICATION FOR PERMIT SAN JOAGUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1Complete 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. rI +'ro�u1 Job Address ARoo2 SQuAar eE.vT-slt .2Q_fl6 W. rue..uER jNtly LODr Lot Size 1104 PM .Zohn G. No.tMo-n,r Robert t-, L*ird_ _ �!p $a.tof avrlL+fi[Cr. Owner's Name '�r�nem T Laird W.'fiiati„ �, 1►lif qtl ess -I}ne $o.�nvarnl OrriHnr acl4 Phone(/ - O S� �c�uIrn' , i`� Sty k. �'�� Contractor LE t rZ Lc, Adaress �[tl"certse No.X 57- ST1Z2 G$�,cr2 31iG_170 e }3 (a TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT G DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER $ 49.9r Plot >:DISTANCE TO NEAREST: SEPTIC TANK > /0' SEWER LI 7ES > is DISPOSAL FLD. PROP. UNE FOUNDATION > AGR LZE WELL OTHER WELL PITS=SL:1PS INTENDED USE TYPE OF WELL P .OB`•EM'AREA"'jONSTRUCTiON SPECIFICATIONS ❑ Industrial ❑ Open Bottom Manteca` ia. of Well Excavation Dia. of Weil Casing ❑ Domestic/Private ❑ Gravel Pack �' 't.;.i T�r�a�c�y Type of Casing Specifications f"1 Public fi Other /' f'i lfa Depth of Grout Seal Type of GroutC�/�rr r arhr Nt I I Irrigation —.Approx. Dep 1 1 Eastern Surface Seal installed by _ Repair Work Done ❑ Type of Pump H-P. State Work Done a Well Destruction 0 Well Diameter Seating Material Itop 501 i Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADOITION I l DESTRUCTION i I INo septic system permitted if public sewer is available within 200 feet.) N x Installation will serve: Residence_ Commercial Other G 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 y LEACHING LINE Cl No. & Length of lines Total length/size " FILTER BED ❑ Distance to nearest: Well Foundation Property Line !� ;SEEPAGE PITS I 1 Depot Size Number SUMPS Ll Distance to nearest: . Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances. stale 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." Contractoes'ihiring 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 applica st call for ail required inspections. Complete drawing on reverse side. Signed X •� �'' Title: La[.�G�s/� pate:. .;IG F DEP ENT USE ONLY Application Accepted by Date 6 d rea 3 ";Pit or Grout Inspection by Date Final Inspection b Date�z Additional Comments: -❑ Stk 466-6781 ❑ Lodi 369.3621 C Manteca 823-7144 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA F-201 FEE INFO AMOUNT DUE AMCI;HT.REMITTED CASH RECEIVED BY DATE ?E.Z4ma tiD. /EH13-24 IPEV,I/M Se D�3?-(>,3 EN 14-28 �( V