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c } i APPLICATION FOR PERMIT Zo O ,� M SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,,STOCKTON, CA recti Telephone (209) 466-6181 * , PERMIT EXPIRES'1 YEARjFROM DATE ISSUED ;. lo XA (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. i Job Address r T'r ' Vr t/ It� .City f N (ALot Size YPM S „.� .. ;. Owner's Name + N� 1 �`� Address Phone Contractor CqRG f Address l`-� �4 S�"J ' }'Ie License No. Q Phone E).2 6!S 8 !SS TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS —1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia._of_WellZxcavation y Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑'Tracy Type of Casing 1 Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern _Surface Seal Installed by' Repair Work Done ❑ Type of Pump H.P. State Work Done x Well Destruction ❑ Well.Diameter Sealing Material (top-15'01- Depth op60'!-Depth l Filler Material (Below 50') ? TYPE OF SEPTIC WORK: NEW INSTALLATION K REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if publi6:sewer is available within 200 feet.) Installation will serve: Residence <4Commercial !her i Number of living units: _L_\\'Number of b Brooms �. 3 r } �Nl I Character of soil to a depth of 3 feet: _ k!6 LO_#"- Water-table depth SEPTIC TANK ❑ Type/Mfg ( �Cs/4 T Cap Ica h7_-1-690 6-A'I Compartments PKG. TREATMENT PLT. ❑ I l J:�Method_of_isp Distance to nearest: 1%Uell Foundation Property Line LEACHING LINE LJ No. & Length of lines VO Total length/size -d() F+ B�D '�� a to{nearest: SEEPAGE PITS 9-Depth Size- I X l U Number # 9 SUMPS ❑: Distance to,nearest: Well OUB 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 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 oY°.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 per ns subject to workman'sicompensa- tion laws of California." ! The applicant must call for all re wired inspe ons. Complete drawing on reverse side. f r ► Signed X � } Title: �`"� - Date: �•�� FOR DEPARTMENT USE ONLY x Application Accepted by Date i# 4-6 r Arear Pit or Grout Inspection b Date Fi-hal,insoedion f7I Date Additional Comments: "' Q-- ^� N ( N ❑ Stk 466-6781 ❑ Lodi 369-3621; ❑ Manteca 823-7104 ❑ Tracy .835 5 -- �_-.i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O..Box 2009, Stk., CA 95201 ; INFO FEELAMOUNT DUE +f AMOUNT REMITTED CASH RECEIVED BY' DATE PE/R�MI`T'N7O. + EH.13-241REV.1iys1 f D—o v .""«- 3057 f ��J —7-1q— 9& EH 14-26 i f yl..V- ...__._.._.. _._._ _... .... .