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k p APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA �` �t"�3 ! Telephone (209) 466-6781 ,,�• _ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) tf LGI Application is hereby made to the San Joaquin Local Health District for a permit to constfuct 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 Addresse�—/! t / City/ Lot Size PM Owner's Name _ ,nF fAddres"s /,3 !// ��,•�� Phone Contractor L—OY GtJ0ViD Address�, .9�s r�Pr RT License No. 5_x,s-7 Phone _3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION�❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE-TO-NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE T T- FOIJNDATiON AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open BottomI ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 ❑ Domestic/Private O Gravel Pack ❑ Tfacy Type of Casing Specifications 1-1 Public F1 Other Ll Delta Depth of Grout Seat 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' Sealing Material Imp 50'1 -Depth ' Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADDITION I I DESTRUCTIONINo septic system permitted if public sewer is ' ailable within 200 feet.) Installation will serve: Residence=+, Commercial_ Other 4' ^ , "� Number of living units: Number of bedrooms JLt Character.-of soil to a depth of 3 feet-.' Water table depth SEPTIC_TANK r ❑ Type/Mfg I' Capacity No.'Compartments 3 PKG:•TTREATMENT PLT.-LJ TM Meth(5d of Disposal I ~ ' µDistance to nearest: Well Foundation Property Line LEACHING LINE ! ❑ No. 8r L'erigth•of lines Total length/size FILTER BED i ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depths-1- _ Size _ NumberY �. SUMPS 1 Ll Distance to nearest: Well Foundation PropertVLine 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 licerised 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 California." The applicant must call for.,all-required-inspections.'Complete.drawing on-reverse side, 5 Signed X Title: - Date:- to-/0 -17 SF DEPARTMENT:uSE ONLY Application Accepted by Date 1C)��I Area . Pit or Grout Inspection by Date ] Final Inspection by `4- Date f� Additional Comments: �/ 1 ❑ Stk 466-6781 ❑ Lodi 369-1621 ❑ anteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copi s to: Envi onrrienta Health Permit/ ervices 1601.E. azelton Ave., P O. Box 2 01 9161 — V k.6 +o L0 �W-tr- PU4 z - F,FEE -4, iNFO MOUNT DUE i AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT'NO. � EH 14-20 + EH 13-24{REV.r/A 51 (!CJ y 1