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APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DA I r,-f;.•,:•,r; ....•n:;;; (Complete in Tripli e) Application is hereby made to the San Joaquin Local Health District for s permit to c 1.�7of r Install the work herein describod. This applicirion is made in compliance with San Joaquin County Ordinance No.519 for sewage or No. 1 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.,c:I4r;I; ,11-1 lt• .. .�•::^ ::' - - ;t. It , Job Address Winn(5 �t.z, On.a•C C/i�ry_(-(-/'inn. . Lot Size 5 r7 Crr< PM Owners NamefivalR LI,:�14c,..�_,a,.J�Se.,< _ Address L6t601 S. IJa...+., {[�n_,t Phone 9436' ell ^ 3%6 77- Phone / Contractor U rt I i Address '. � TYPE OF WELL/PUMP: NEW WELL AC WELL REPLACEMENT ❑ DESTRUCTION ❑ cs,�-%w�� -PUMP INSTALLATION ❑ SYSTEM"PAIR ❑ OTHER ® aocl� DISTANCE TO NEAREST: SEPTIC TANK Ser, lk SEWER LINES DISPOSAL FLO. PROP. LINE-'U FOUNDATION � AGRICULTURE WELL OTHER WELLS`.. PITS/SUMPS INTENDED USE i TYPE OF WELL i PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ,❑ Open Bottom ❑ Manteca Dia. of Well Excavation rke4« Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack JKTracy Type of Casing S<_k 4n P U G Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 17 �-e c'-_ Type of Groutr • o ❑ Irrigation `ro' Approx. Depth ❑ Eastern - Surface Seal Installed by b •r I Repair Work Done ❑ Type of Pump, a H.P. State Work Done Well Destruction ❑ Well Diameter_ Sealing Material (top 501 Depth_±L0�+ Filler Material (Below 50.1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted 8 public sewer is , available within 200 feet.) Installation will serve: Residence_ Commercial_ Other L Number of living units:_ Number of bedrooms f Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ' ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT.❑ I Method of Disposal L Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property.Line SEEPAGE PITS ❑ Depth Size Number SUMPS - ❑ Distance to nearest: . Well Foundation Property Line DISPOSAL PONDS Cl 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 California." ' J - . The applicant must ca I for a requi.rr�ed inspections. Complete F�drraawing on reverse side. qqxx Signed X, a �^C 4- r /�iuGO A='1 ('^Title: Sfa« G'GO10�75� Data: FOR E ONLY Application Accepted by Date yd Area 3 Pit or Grout Inspection by Date 20 Final Inspection b Date Additional Comments: ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83543365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 671 rl0-375 CK NFEEFO AMOUNT DUE AMOUNT REMITTED CASIf RECEIVED BY DATE PERMIT N0.