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.4°L )CA, r I X14 i 4 APPLICATION FOR PERMIT � �� rr. � �� SAN JOAQUIN LOCAL HEALTH DISTRICTI' l 1601 E. HAZEL T ON AVE.; STOCKTON, CA Telephone (209) 466=6781 yk W PERMIT EXPIRES 1 YEAR FR6m DATE ISSUED (Complete in Triplicate) pM\l E S- Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herei�r 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 1r t✓1{✓� �� City ` Lot Size PM 1 Owner's Name l? /Ili 1 Address �` . Phone r��Jl��p 'Contractot` �.+Lr�� = LAZWOW,ess" - �/� = u -License.No..`-7 -Phone,57767 Y { TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION r 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`l Public f7 Other Cl Delta Depth of Grout Seal Type of Grout _ "r I I Irrigation Approx. Depth i I Eastern Surface Seal Installed by 6 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Weil Diameter Sealing Material [top 501 V1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I:I REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is 1 l available wilAO 200 feet.I ,J Installation will serve: Residence Commercial_ Other Z Number of living units: Number of s •p 7p � m n i Character of soil to a depth of 3 feet: Wa 9-le depffi SEPTIC TANK ❑ Type/Mfg Capacity No.lrl�artments v9i-0 PKG, TREATMENT PLT. ❑ MetM7aDispSs'iI Distance to nearest: Well "Fo�d.flo�rProperty.Lintv� ' LEACHING LINE ❑ No. & Length of lines Total length " e r" s&1 FILTER BED ❑ Distance to nearest: Well Foundation Property Li e i SEEPAGE PITS I I Depth Size Number SUMPS ❑ 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 Di%trict. 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 become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify th i the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws 'ornia." The app cant mu c II f r 11 re '"pections. Complete drawing on r v rse side. rr t Signed X Title: Dater d� FOR DEPARTMENT USE ONLY x Application Accepted by , i Date ` O / Area x : ^f� Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 " ❑ Lodi 369-3621 ❑ Manteca 1323-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH + EEH H 1424IREV.t/85S �" I �� g C> ��'��/Z1 `l