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(-f�• �� r APPLICATION FOR PERMIT ,r,r ,7 L4l(6) SAN JOAQUIN LOCAL HEALTH DISTRICT 'u""_ / 1601 E. HAZELTON AVE., STOCKTON, CA OJ f i_-w v P- Telephone 1209)1466-6781 now6vvu PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . l (Complete in Triplicate) x: 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 --Z- 2 � �� 1 L(_q c L) 45T_ .*,C;ty _3C '.-Lot Size PM Owner's!Name Le ST E 2 W m t�y� 2 Address � � �® t� [�r L i�Q lJ S T Phone i Contractor-D'A r pf�RR1'51j f SQ!QAddress_3S90 f0C113fL6oLj icense 3z1_3 Phone 9�_W69 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO f I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i< INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial t ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public A ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation fa ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump, - - H.P. ' State Work Done Well Destruction ❑ Well DiameterP Sealing Material (top 501 ° Depth i Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑, REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is Y i . ,� available within 200 feet.) Installation will serve: Residence Commercial_ Other i Number of living units: Number of bedrooms' Character of soil to a depth of 3 feet: c, t Water table depth SEPTIC TANK Type/Mfg . Capacity s No. Compartments PKG. TREATMENT PLT. ❑ ; ` f ( Method of Disposal Distance to nearest: Well Foundation ? Property Line j LEACHING LINE ❑ No. & Length of lines Total length/size 4 FILTER BED ❑ Distance to nearest: "' Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest:-^^Well" Foundation k Property Line 1 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 s - <_ J 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 subcontracting 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/at call for"uired i s r ctions plate drawing on reverse side. Q Signed Title: Oben�- Date: f? FOR DEPARTMENT USE ONLY p Application Accepted by _ Date T�i_i!t Area 0 O Pit or Grout Inspection by, ` Date` Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy.-835-63% Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.-, P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE.; AMOUNT REMITTED CASH 1) RECEIVED BY DATE PERMIT`NO. + EH 13.241REV.r/as) EH'14-28 i