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♦ APPLICATION FOR PERMIT +` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 9 a (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./7 G Job Address v ♦�14r-1,1 ��,1City S G�ON Lot Size PM Owner's Name /rll�/>°j�pfl/J'/V 1 (rit"'/pl'V�/ �/y'ryApd'd`IOWD/�c/ /J�.s/�/ .yds-1.�� Phone 24 -A0e-F` Contractor ,l t/ `�eIC[L r Address7r!✓ D0AW0`10 /�r+r pie License No. Phone/%36ky_fQ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �5,� �� f'1 Public ❑ Other ❑ Delta Depth of Grout Seal y Type of Grout FSR- I Irrigation __Approx. Depth I 1 Eastern Surface Seal Installed by�t`' Repair Work Done ❑ Type of Pump H.P. State Work Done '�.7W[ell Destruction ElWell Diameter Sealing Material (top 50') oft $D(!` Depth Filler Material (Below 501 TYPE OF SEPTI WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other pti 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 r 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." 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 st call for all r red /ligds,�omplete drawing on reverse side. A , Signed X '%s/ Title: la �g�� Date: �T FOR DEPARTMEN USE ONLY L7 Application Accepted by iLl! Date —I ^ Area Pit or Grout Inspection by Dat Final Inspection by Duane Additional Comments: � S C�.lIfU(OILF4% UIPT[A;t4T' IA�V6C7k� Vaw ia1 &fOZ(.TS 11pe E) Stk Stk 466-6781 ❑ Lodi 36b�621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 Applicant- t r I copies tonvironmental_Heelth Pe 't/Services E. Hazel on Ave., F. _O=20D;), Stk., CA 952_ 011- . INFO AMOUNT DUE AMOUNT flEMITTED K H RECEIVED 9Y DATE PERMIT NO. ♦ EH 13-TA IREV.r/xsl l .0� TZ.A � 1]/ _ �I / ^ � I '1 _Z EH' •T ` v�J� Vr,�' lY 0 1 61 `