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APPLICATION FOR PERMIT lro i ,r ,, t... 1•� � �,� tip''. aL� ..�. I SAN JOAQUIN LOCAL HEALTH DISTRICT # 1601 E. HAZETON 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 welUpump and the Rules and,Regulations of the San Joaquin Local Health District, Job Address / 7 /f /J,,2-` -4a-n--c_ City IsZOd''J 7 t- Lot Size4"1 , PM Owner's Name t1��'l �aG�1)� .__ _ __Address �S �� C �".I'c> lT*�i Phone 7,? 0 Contractor 0 CD, Address��Q-945 '°A7 MaJft' License No. V-423 Phone �s6i.3 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ 7 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK IS + SEWER LINES /SO z-t- DISPOSAL FLD./SZ)_ PROP. LINE i' FOUNDATION /pd � AGRICULTURE WELL "BOTHER WELL � PITS/S.,t.JMPS' INTENDED USE TYPE OF WELL PROBLEM AREA CON STAUCTION_SPECIFICATION < !! ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casinj t Domestic/Private ,Gravel Pack , ❑ Tracy Type of Casing—P YC- Specifications Cl Public n Other Cl Delta Depth of Grout Seal Type of Grout r I Irrigation Ig0-0-Approx. Depth I I Eastern Surface Seal Installed by _ �- Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') [ k Depth Filler Material (Below 50') q� TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet./ Installation will serve: Residence Commercial_ Ot[ief r � Number of living units: Number of bedrooms ,\ �5 i , { .; n % j Character of soil to a depth of 3 feet: x r • Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments {PKG. TREATMENT PLT. ❑ . x' f Method of Disposal t Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED',, ; ❑ Distance to nearest: Well Foundation Property'Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Welli Found�ion Property Line DISPOSAL PONDS ❑ a..r( . ' I hereby certify that I have prepared this application and-tKai tfie work will 6e d`one 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." s t t The applicant m tall fr all equirernspe ions. Complete drawing on reverse side, € r� Signed X—_� uhf -� Title: cap, raG U:� Date: I FOR DEPARTMENT USE ONLY t i I Application Accepted by LAC, 81 Date Area Pit or Grout Inspection by�' Date Final Inspection by Date } Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 .❑ Manteca 823-7104 ❑ Tracy 635-6385 1 Applicant-- Return all copies to: Environmental Health-Permit/Services.1601 E. Hazelton Ave:',-P.O.-Box 2009,-Stk.,/-CA 25201FEE [ * .. INFO `AMOUNT DUE AMOUNT REMITTED CK V CASH RECEIVED BY pg7E PERMIT NO. r EH 13-24 IREV.I/H 51 l0 yl !—,— lq��L Z" EH 14-215 ""