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.i Ik APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA i€ Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ! �+ (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. 'I Job Address ' ? Y O Al Fel T(Son 13 — City IoDf Lot Size +_0 0.4— PM Owner's Name Mel- GAR"12a �t Address Ste-- Phone i �7 � it e1 Contracior m'SS Se Address "(7� S etr15�� b License No. 3 ©�� Phone_ TYPE OF LL/PUMP: 1! NEW WELL d WELL REPLACEMENT ❑ DESTRUCTION ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR [,T_� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS EJ Industrial Q'Spen Bottom 71Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 71 Public FI Other f=1 Delta Depth of Grout Seal Type of Grout _ Wrrrigarion .-Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Miferial (Below 50') – TYPE OF SEPTIC WORK: NEW INSTALLATION Il REPAIR/ADDITION I I DESTRUCTION I 1 I tic system permitted if public sewer is 0 P I�1 r all bl within 200 feet.) Installation will serve: Residence— Commerci �++ Re ".X �ti r Number of living units: Number of bedrooriis i� ^"}} Character of soil to a depth of 3 feet: 1{{�.0UtWater table depth SEPTIC TANK ❑ Type/Mfg redo. Compartments PKG. TREATMENT PLT. ❑ WOM DefY 60 /� �y ` i�x}�yMethod of Disposal Distance to nearest: Wil t1 i i ndatAL Hea 1 r F' pe`rty Line ,,. LEACHING LINE ❑ No- & Length of lines Total length/size FILTER HED L3 it Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size _ Number J 3 SUMPS ❑ Distance to nearest: --Well— 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. .'' r { Nome 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 sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." I The applicant must ca for all requiredin ctions. Complete drawing on reverse side. Signed X it Title: Date: _ r i i FOR DEPARTMENT USE ONLY ii Application Accepted by Date 2g Area k Pit or Grout Inspection by .i Date ' Final Inspection by Date Additional Comments: 'fit etc, r Mb ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies',to: Environmental Health Pefmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH a.EH 13-241REV.t/ri51 EH 14-26 'SCJ