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APPLICATION FOR PERMIT SAN JOAQUIN'LOCAL HEALTH DISTRICT ` 1601 E. HAZELTON AVE., STOCKTON, CA 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address _ 77,G-0 ]_/J4 City >r`iG Lot Size PM { r I Owner's Name _M"-4-0.Q Lid �-r Gress 72$Q V/d yIV I"L-0 -Phonev61-- Contractor' -.L-p Address MY(ZILIF S t License No. 7�Z Phone 3 ' 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 WELL PITS/SUMPS .e INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrialifjy/10- tg Ll Open Bottom El Manteca Dia. of Well Excavation q Dia. of Well Casing 2 ❑ Domestic/Priva d ❑ Gravel Pack `4 Tracy Type of Casing__- fir` PV'C- Specifications ❑ Public 1�Other ��( ❑ Delta Depth of Grout Seal — �2 r Type of Grout 95k SfFw ❑ Irrigation !]C�Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter 6�i Sealing Material (top 501 Depth_ 70r 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 vl SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size f FILTER BED - El Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ 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 District. 4 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 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. f �/ Signed Title: 45AV 4b45 Date: DEPARTMENT USE ONLY FO Y Application Accepted by .. . e � � Area 17 pe Pit or Grout Inspection by /�-c�� `�Date Final Inspection ate Additional Comments: �' ew /d"!2Ae 100e,A -�� ❑ Stk 466-6781 ❑ Lodi 369-3621 97manteca =,664 ❑ Tracy 5-6385 T } Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED LASCK H RECEIVED BY DATE PERMIT`'N0. + EH 1 -24(REY.1/65) �` �� •�� EN f44-28 &-