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APPLICATION FOR PERMIT n SAN JOAQUIN LOCAL:HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District: Job Address �"'" ` ^ 1-1.1 Li ye, & City Lot Size PM Owner's Name © �+ L Ic � �"`' = Address ..O �� J Phone '� • `$ Contractor Yv AcIr ' Address 3 SO "` . C` ` License No. 3 d Phone TYPE OF WELL/PUMP: NEW WELL:0 ; WELL REPLACEMENT ❑ DESTRUCTION ❑ -;.----- PUMPINSTALLATION.❑.� --= SYST.EMjREP.AIR_❑M�`�---.,._-.-OTHER-O- --- -.----r-----=--r- DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE -TYPE OF WELL #3 PROBLEM AREA-r CONSTRUCTION PECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mahteca, Dia: of Well Excavation Dia. of Well Casing + ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications —19-Public- 19-Public ❑-Other— - --❑ Delta 'Depth=of•Grout=Seal W------ ype-of-Grout ❑ Irrigation --Approx. Depth t ❑•Eastern ySurface Seal Installed by Repair Work Done L1 Type of Pump T H.P. '4'StateyWork pone r .4 ..X _'3 Well Destruction ❑ Well Diameter Sealing Material dtop.50=1 - -- Depth # Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ' i y t a >' ,t , }y r . �`' available within 200 feet.! ` Installation will serve: Residence v _ Commercial ' ther---•� ' Number of living units: � Number of bedrooms �-��I �� _ _ Character of soil to;a depth_of-3 feet:— - C atter fable depth SEPTIC TANK 9_-Type/Mfg :' •_ city No. Compartments PKG. TREATMENT P'LT. ❑ - -; � Method of D' osal Distance to nearest: Well A90 Foundation Property Line f LEACHING LINE & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well r 'J Foundation Property Line SEEPAGE PITS CIl,Depth Size 5. umber SUMPS ❑ Distance to,nearest: �WelbT-/�-�------Foundation—?-OP Property Line F fi DISPOSAL PONDS ❑ I I 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 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 cerci the following:"I ertify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws California." T e applica call for regJinction o drawing on r arse side.SigneTitle: Dater FOR DEPARTMENT USE ONLY "may, � 4 Application Accepted by Data Area pp�� Pit or Grout Inspection by�''� Date Final Inspection by Date L-.J Additional Comments: liw ❑ Stk 466-6781 Lodi 369-3621 ❑ anteca 823.7104 ❑ Tracy 835-6386 i Applicant- Return all copies o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. INFO + EH 13-24 IREV. 1 e 51 D* 8-56 EH 1126