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S7`r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE,, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in-Triplicate) r 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 R41es and Regulations of the San Joaquin Local Health District. '� Job Address I t Iwo ices lll; WOa 'l vty* I-Oc21� Lot Size PM Owner's Name N/19ul S020u& _ Address J.?W.3 �1/ERGA1`� Dk. L4Dr'Phone Contractor Pumismoe Drillem[Xilli �fl g 90 — _3 ��'7-35Y_,k u8��rddress alc to LI�✓1�Enf License No. 1 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE — —FOUNDATION— — --- AGRICULTURE WELL OTHER WELL- _-- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom LJ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal - Type of Grout --Approx. Depth ❑ Eastern Surface Seal Installed by ]� Irrigation �� .:.` Repair Work Done ❑`Type of Pump I MACK lF H. 11:5 State Work Done C.l dniiP Wel! Destruction ❑ ,Well Diameter Sealing Material (top 501 E --Depth Filler Material {Below 50') TYPE OF SEPTIC WORK; NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available.within 200 feet.) Installation will serve: Residence_ Commercial_ Other -T - Number of living units: Number of bedrooms - Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK O j Type/Mfg j Capacity No. Compartments PKG. TREATMENT PLT..❑ i F Method of Disposal E Distance to nearest: Well Foundation Property Line } LEACHING LINE No. & Length of lines. l4 Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS "Ll Depth Size 3 Number ".SUMPS v❑-' Distance to nearest: Well Foundation Property Line k K ._y DISPOSAL PONDS ❑ 41- I 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 workrnari'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 employ persons subject to workman's compensa- tion laws of California." The applic myst cal all quired inspections. Complete drawing on re rse side. Signed Title: ��, ora 1-� Date: --� -�� FOR DEPARTMENT USE ONLY _4 Application Accepted by Dated _ Pit or Grout Inspection,by _ _ La_ r'inal Inspection by Additional Comments: ! ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 :f; ;. : ' s Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952Ea1''' 'a .1- 0 }CK# __. INFO AMOUNT DUE FEE AMOUNT REMITTED CASH RECEIVED BY DATE PEf4fT No, X +EH 13-24 1REV.1ie5r rr r�., 4I EH 1428 �tpt