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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRESu1 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. G Job Address L 11. r C Ora D ,ice i L' City L. 4�l / Lot Size: ,PM Owner's Name L d. .I.S /Y7'cs LL p Address [ q Phone Contractor's Name Uti f e/ A Lv ' License No. 6 / Phone 7 f'?;7 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION,r T SYSTEM REPAIR❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ y pro SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �t ❑ Industrial a� •❑ Open Bottom ❑ Manteca Dia. of Well Excavation !.,? Dia. of Well Casing ))Domestic/Private Gravel Pack ❑ Tracy Type of Casing VC. Specifications ❑ Public ❑.Other ❑ Delta Depth of Grout Seal D Type of Grout ❑ Irrigation .--Approx. Depth ❑ Eastern Surface Seal Installed by P.c. (z-rod U F, L.L t d6- Repair lG-Repair Work Done ❑ Type of Pump SUJ3 iH.P. Y2- State Work Done Well Destruction ❑ Well Diameters Sealing Material (top 50') 0>20 UT Depth f 6�0Filler Material (Below 501 6a& 6-4-a Ver L _ T SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will se Residence_ Commercial_ Other Number of living units: umber of bedrooms j Character of soil to a depth of 3 feet: Water table depth t :SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 71i 4 Method of Disposal Distance to nearest: Well dation Property Line .LEACHING LINE . ❑ No. & Length of lines ength/size FILTER BED ❑ Distance to nearest: Well Foundation Pro Line f SEEPAGE PITS ❑ Depth Size Number <�— SUMPS " 17 :Distance to nearest: Well, Foundation Property Line �4w 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 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,I shall employ persons subject to workman's compensa- tion laws of plicant California , The apm I all requ' d Pdolions. Complete drawing on reverse side. Signed Title: Date: - FOR DEPA TMENT USE ONLY Application Accepted by + Date Pit or Grout Inspection by Date Final Inspection by ,Date Additional Comments: El Stk 466-6781 1-1Lodi -3621 638 Manteca 823-7104 O Tracy 835. 5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,.Stk., CA:95201 NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. .-I p �b O +EH 1324(REV.10!891 EH 1426 ! '•b Z] '� ��r i�(v K-6