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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.''HAZELTON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES TYEAR 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. �^ ,j� �[, �.,, L_ II Job Address Lol Sore i■I V�k K City S"t XR!A Lot Size PM .500 Ar;RPoRT 1ILVD, 5ufre zea Owner's Name MD i�� S Address Qt,�JWAJ�s/4�}�+ q'lrort0 Phone Contractor S'P 77NA O(PLOR4704Address 7.S OiS�r_ /4V97Z 6 Sr License NoCSZ-9(726? Phone. i TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER >r3 M0N1�21NC-r WE'LL f+ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL ____ OTHER WELL PITS/SUMPS Q INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS // 0 Industrial 11 Open Bottom ❑ Manteca Dia. of Well Excavation fA 1s Dia. of Well Casing 444CP 0 Domestic/Private 'Gravel Pack(5")❑ Tracy Type of Casing FYBO PM Specifications f-i Public 17 Other Cl Delta Depth of Grout Seal tQ Type of Grout I I Irrigation -N 39_Approx. Depth t I Eastern Surface Seal Installed by _ Repair Work Done 0 Type of Pump H.P. State Work Done _ G Well Destruction 0 Well Diameter Sealing Material (top 501 f Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDlftQ(�I DESTRUCTION l I Wo septic system permitted if public sewer is f �P available within 200 feet.) Installation will serve: Residence Commercial_ Other fx, EX P 4 11 th I Number of living units: T Number of bedrooms 1 if4 Character of soil to a depth of 3 feet: �rrn L W11,itJEPZth SEPTIC TANK ❑ Type/Mfg �lf1Cf{t ire sty b�xDIMACV art ents PKG. TREATMENT PLT. ❑ 111I ft Complete �ethnic 0sposal Distance to nearest: Well by i", #�i� � Pq(erfy'01 ' LEACHING LINE ❑ No. & Length of lines Total length/size ��rf{7Tr FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS t I Depth Size _ Number 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 Di1trict. 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, 1 shall not I 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 California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: ROnLCkLrA L;,-I G—G�,nZe►' Date: 1e�f L I90 FOR REPARTMENT USE ONLY ��fJ! aye r Application Accepted by �E'G!�. _C.1/� Date O Area - Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 j Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. I INFO CASH �`y +.EH13-24{REV.i/n 5) r/ _ 7 426 EH 1 i