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APPLICATION FOR PERMIT j SAN JOAQUIN LOCAL HEALTH DISTRICT 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 the Rules and Regulations of the San Joaquin Local Health District. t Job Address l . ICJ �IL1 City Lot Size L1�—SLS PM Owner's Name�IT8)66kL "-,1 Address f� �! c� Y L_/l ll_�_{ - C Phone Confra�cto�r � 2 Add ss (�� License No.C�O_ksl Phone U TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION SYSTEY REPAIR 0 THE ❑ DISTANCE TO NEAREST: SEPTIC TANKf '�,�_ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION r�--P- :Q__ AGRICULTURE WELL OTHER WELL TS/SUMPS— INTENDED USE TYPE OF WELL PROBLEM-,AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia:of Well Excavatio Dia. of Well Casing Domestic/Private V_Gravel Pack ❑ Tracy Type of Casing—, PIp L, Specifications FI Public n Other Cl Delta Depth of Grout Seal Type of Grout p I I Irrigation _.-Approx. De th I Eastern Surface Seai Installed by _ Repair Work Done Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (tap 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION E I DESTRUCTION i 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other j Number of living units: Number of bedrooms j Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK F) Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ID Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Cl 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 Diltrict. 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 t call for all required inspections. Complete clrpyving on reverse side. r � Signed t Titla: l�l�_1� 1 Y 1CC�f _ Date: d r el FOR DEPARTMENT USE ONLY Application Accepted by Date -4 Area Pit or Grout Inspecti y4VV 4L-2Date /'d73 Final Inspelction by Data I Additional Comments: S W 0 Stk 466-6781 ❑ Lodi 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 95201 ~ (NFO FEE AMOUNT DUI: AMOUNT REMITTED K H RECEIVED BY DATE PERMIT NO. t.EH 13241REV.iinsl D �� ., �r). �riL/. -7C� . EH 14-M 6 4 Z�oS ;