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i Ai APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES # YEAR FROM DATE ISSUED (Complete in Triplicate} Application is hereby made to the SanfJoaquin Local Hoakh District fora pormit to construct and/or install the work herein described. This application is lnade in compliance will, San Joaquin Calmly Ordinance No. 549 for sewage or No. 10G2 for well/pump and ilio RulDs and fiogulanons of the San Joaquin Local Flealllh Oistlicl. I c - Job Addross1~ LCit l Y– •`I 0 Lot Sizes00+ Z_._._. � PM Owner's Name �� Address Contractor noctF-Mot COhSv.��qu lAddress.I..'3 F=(LtjMv, License No.o, qh c Phone S2 TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION LI Gea�ec�r.n�.0 PUMP, INSTALLATION U SYSTEM REPAIR C7 OTHER SptL `1t11� S DISTANCE TO NEAREST: SEPTIC TANK ��oN-\- SEWER LINES �� DISPOSAL FLD.�15t;PROP. LINE >1 0 FOUNDATION 1S _ ONA--AGRICULTURE WELL 7! •BOTHER WELL OTt'PITS/SUMPS 7- Iso-Tv-INTENDED USE - � � TYPE OF WELL PROBLEM AREA C _ ONST'RUCTION SPECIFICATIONS L.1 Industrial f 1 Open Bottom (3 Manteca D Fl ia. cI Weil i xcavation Dia. of WN i � _ ell Casing 4 Domestic/Private C] Gravel Pack 13 Tracy Type of Casing Specifications _ VI PilhGc I I Ia Other Fl Delta Depth of Grout Seat Typo O TYpe of Grout lrrigalion _—Appiox. Deplh I I Eastom Surface Seat Installed by aAQ Repair Work Hone 1_7 Type of Pump H.P. Stale Work Done Wel! Destruction I_] Well Diameter Sealing Material (topre, C *11c. Depth Filler Material (Below 50'j TYPE OF SEPTIC.WORK: NEW INSTALLATION t I REPAtH/ADDITION I,1 DESTRUCTION I I (No septic systorn permitted if public sewer is installation wavailable wilhin 2D0 fact.)ill serve: Residence Commercial_ Other _ Number of living units: Number of bedrooms Character of soil 10 a depth of 3 feet: Water table depth r SEPTIC TANK fa Type/Mfg Ca Dell P Y ' _ No. Compartments PKG. TREATMENT PLT. LI f Method of Disposal r Distance to nearest: Well foundation Property Line i LEACHING LINE- hT No. & Length of tines Total length/size FILTER BED 1:1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Doplh Size x r � Number SUMPS 1.1 Dislance to nearest: Well, Foundation Property Line DISPOSAL PONDS I I hereby certify that I have prepared this'application and that die work will be clone 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 1118 following: "I certify that in the performance of the work for which Ili!s permit is issued, I shall not employ any person in such niannor as to heCOrne subject to workman's componsation laws of California." Contractor's hiring or sub is signature certifies Ilia following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's cornponsa- tion laws of California.", The applicant musstci�l for` I r inspections. Complete drawing on reverse side. G Signed X� Vow c ``-Fur%iflCWQIu— Title: t�Ol f�r�J►(`tA. _ r � Date: !6 p "' a F �DEAFl ENT USE ONLY Application Accepted by _ Dato 0 _. Kryyyy Area Pit or Grout Inspection by / Date 6 'P"t Fine! Inspection by Date Additional Comments: ❑ Sik 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Sorvices 1601 E. Hazolton Ave„ P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CI( INFO CASH RECEIVED BY DATE PEAM17 N0. E it 13 ZI InFV,t/��•,, Eli r