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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 s' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I 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. n Job Address W i 161 L. (11 e .A 4_0.L le_ �C . City L�r Lot Size PM Owner's Name (ami-S1Sc._._l��.�� 1 Address LLi I F 146,-, - Phone 4 o- L/Y3 ST6 1? C-s-7 Contractor __*_ N I_ I Address � `Tri G�-1� � � ` 1_R_ License No.`f 31(3 3 Phone_ TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 14- —S-0A DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES IVIA, DISPOSAL FLD. PROP. LINE_LeC= FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public l_1 Other F] Delta Depth l— l0 _ Type of Grout I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter _ Sealin 501 Depth rll 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REP AD O 1 I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Resident _ �C a cther Number of living units: N be 6A bedroom Character of soil to a depth of 3 fe Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ / Method of Disposal Distance to nearest: W 11 Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length size FILTER BED ❑ Distance to nearest: Well Foundation Property Line L :4 SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line J DISPOSAL PONDS ❑ CT 1 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 Califor The applicant call for all requi in actions. Complete drawing on reverse side. Q Signed X Title: (�i_`f f Date: e�Q 'GaT FOR DEPARTMENT USE ONLY Application Accepted by Date J ( Area / Pit or Grout Inspection by Date 5 �y Final''Inspection``by Date Additional Comments: �� "^� 4. -,3e�Q If L3, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca tt823-7104 ❑ 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 RECEIVED BY DATE PERMIT'NO. INFO CASH . EH 13-24(REV.r/N5) �. _ 7 / —IIP