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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZE.T ON AVE., STOCKTON, CA S � Telephone (209) 466-6781 r � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �` `r (Complete in Triplicate) Q Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. Thi pplication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for weVpump and the Rules and Regulations o e San Joaquin Local Health District. Job Address _ ,f IEIf,✓_ma 4 AQ is City Lot Size PM �y�7 P0. BGx vim// Owner's NameAR ,QCo / du [/J-Y/YYIDdW Address G Phone t7 so �V Lf VA 6,4 St -5(J;k 3 Contractor Address_RQ45PJr1/G L4 c7!`�/fig License No Phon�� ~Q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ©/ERWELL— TRUCTION Monl�I'�A) PUMP INSTALLATION ❑ SYSTEM REPAIR aOTHER`)4 1g6rZf r)A1 Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DO. PROP. LINE r FOUNDATION AGRICULTURE WELL O PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION §PECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Ex vation hal Dia. of Well Casing ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casi g ]l 1. qo PyL Specifications (`i Public Cl Other Cl Delta Depth of rout Sea( �'- J Type of Grout 16A1 i I I Irrigation i.Approx. Depth I 1 Eastern Surfac Seal installed by Repair Work Done ❑ Type of Pump tf H.P. State Work Done Well Destruction Well Diameter �rial (top 50') &Jell Depth Filler Ma rial (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIA ITION I I DESTRUCTION I 1 INo se p , syste rmitted if public sewer is availab within 200 f Installation will serve: Residence_ Commercial— ther Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Wal r table dept SEPTIC TANK ❑ Type/Mfg Capa y No. 0 ments PKG. TREATMENT PLT. ❑ ethod of Disposal Distance to nearest: Well Fo ndation Property Line LEACHING LINE ❑ No. & Length o limes Total length/size FILTER BED El Distance ton rest: Well .ndation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distanc to nearest: Well Foundation Property Line DISPOSAL PONDS Q I hereby certify that I have prepar 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 oaquin Local Health District. Home owner or licensed agent' 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 ma ner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the follow, "I cert y 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 Calif. ni ." The applicant ust all fo all rezmzt, :�L omplete drawing on reverse side. Signed Title: ' ��[.� Date: • FOR DEPARTMENT USE ONLY Application Accept by Date J'^/� Area Pit or Grout Ins tion by Date Final Inspection by Date r Additional Com ants: qr .+an ❑ Stk 4f 67 1 1-1Lodi369-3621 Manteca 3-7104 ❑ Tracy 835-6365 Applicant - R urn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 � Q A NFO CASAMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT'NO, !JJ (� +,EK 13-24(REV.t i K 5) Z EH 11-26