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APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE.,•STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROIUI.DATE ISSUED r rlsxsluFii„- ; .. (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 ! J �Q LjgS /W,q • s - q City t)G n iv,Lot Size PM Owner's Namet -2 l ucc r Address _ h M Phone Contractor A k' ai S )AIS Address ye &/,,SO ~ 66'�96Q License No-Z"---1y-3—Phone 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 FOUNDATION AGRICULTURE,WELL OTHER WELPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ; ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation # D Domestic/Private Gravel Pack El Tracy T Dia. of Well Casing El of Casing Specifications ❑ Public ❑ Other El Delta Depth of Grout Seal i ❑ Irrigation A ii Type of —. Grout pprox. Depth ❑ Eastern Surrface Seal Installed by 1 _ Repair Work Done ❑ Type of Pump H.P. # State Work Done Well Destruction Cl Well Diameter Sealing Material (top 50') DepthFiller Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No'septic system permitted if public sewer is Installation will serve: Residence✓ Commercial Other available within 204 feet-1 I Number of living units: _L Number of bedrooms Character of soil to a depth of 3 feet: 4 ❑ T SEPTIC TANK Water table depth ype/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line = LEACHING LINENo. & Length of lines 3 dI Total length/size �Z FILTER BED „ _ O"—Distance to nearest: Well /-?S _ Foundation SO 11i Property tine SEEPAGE PITS Depth S , _Size I Number Z _ SUMPS B'�Distance to nearest: Well Foundation - tt O Property Line DISPOSAL PONDS ❑ t hereby certify that I have prepared this application and that the work will be dorie�in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. �r A, � �l i Home owner or licensed agent's signature certifies the following: "1 certify that in the perforrnance'-of tfie-workrfor•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."Contractors 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 em Io tion taws of California." v PJ Y persons subject to workman's compensa- tion ill The app7=� ail requir d inspections. Complete drawing on reverse side':' t ' Signed � Title: . Data: / - �r L5 6 i FOR DEPARTMENT USE ONLY Ap lication Accepted by Date �7�O Vpl Area Pi r Grout Inspection by Date, speby Date Final Inction !�1 r Additional Comments: ❑ Stk 466-6781 ❑ Lodi anted' 823-7704 i ❑ Tracy 835-6385 ! Applicant- Return.all copies to: Environmental Health Permit/-Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201. FEE CK � INFO AMOUNT DUE�- AMOUNT REMITTED RECEIVED BY 1 CASH- ti� �.,h HATE PERMIT NO. '+ EH 13-24IREV.tixs) -- � -f -�6- 110 ` EH 14-28 t