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Y APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i "` (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. /# Job Address 7 9��SC1_ d�Q J�s�✓ !GUC9CJ Cit1 Yl FPS Lot Size PM Owner's Name � Address Phone 2=0 � 00 Contractor Cy i Address < - eve cls 4VL* YIWCU�, License Nola-9--#9t Phoneme �' 7Iy� 7`J TYPE OF WELL PUMP:' NEW WELL ❑ WELL REPLACEMENT 'O DESTRUCTION ❑ I 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 f l Public ❑ Other I ❑ Delta . AI Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by ! � t Repair Work Done ❑ Type of Pump H.P. State Work Done_ t Well Destruction ❑' Well Diameter 1 Sealing Material (top 50') DepthI Filler Material{Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION AQ REPAIR/ADDITION I I DESTRUCTION l 1 Wo septic system permitted if public sewer is I available within 200 feet.I 'Installation will serve: ' Residence lCommerciaf Other F LNumber of living units: -..�_ Number of bedrooms f Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK t I] Type/Mfg LIACr Ca acit o� } _ - P Y—/..-.�l'�l No. Compartments r PKG. TREATMENT PLT: ❑ ►. ��- Method of Disp?sal r Distance to nearest: Well Foundation Property Line LEACHING LINE { ❑ No. & Length of lines C), r .- Total'length/size- 2—C3 7 r FILTER BED f ❑ Distance to nearest: Well Foundation w Property Line y t SEEPAGE PITS I I Depth Size Number SUMPS LI . 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, an I rules and regulations of the San Joaquin Local Health District. a . Home owner or licensed,�agent's signature certifies the following: 1 certify that in the performance of"the work for which this permit is issued, I shall no 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 "U. —tune tion laws of California." The applic uustcaall-for.all required inspections. Complete drawing on reverse side. Signed ,�,. :C 8 k Title:.y �C3T-r ate'—Gate: 5f'ee` --/3t;:/�/%n tj="�sty••,:/ti:. r .-�-� � .sem 6-'�- G, ,... FOR DEPARTMENT USE ONLY i App nation Accepted by 1 Date Area Pit or+Grout inspection by frDate � _ Final Inspection by _� Date's Additional Comments:i q ❑ Stk 466=6781--°—"-f--Lodi 3i9&:Ji --C-iV ahteca`823=7104 --D'Tiacy 835-6385 Applic nt Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 cw- FEE AMOUNT DUE AMOUNT REMITTED INFO RECEIVED BY DATE PERMl7�N0, ..EH 13-2t[REV.t i K 51 1/ a EH 11-2831 r `�` :el-