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-R" 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) a ' 3_ -C: e j -0/ 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-Address6` �� City L Lot Size + `y Q Cy> PM r-- t' r k. Owner's'NameAddress Phone Contractor P1k.:X Jeal Address � - 1L-- ense No.a51qC?) Phone TYPE-OF-WEL•L-/PUMP:'° NEW-WELL"0— WELL-REPLACEMENT'`❑T —DESTRUCTION-17-1 PUMP INSTALLATION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 4? —F Domestic/Private --O Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout `Q ❑ Irrigation ---Approx. Depth CY Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing.Material.(top 501) l 41 j =1 € Depth Flllef Material (Below 501 f —TYP.E_OF'SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION ❑ DESTRUCTION-El ;(No septic system permitted if public sewer is �. available within 200 feet.) 3 i Installation will serve: Resi ence commercial_ Other � • 1 Number of living units: Number of bedrooms r; Character of soil to a depth of 3 feet: C L,�1 t` f_ �� iWate/tbl,depth SEPTIC TANK E] "Type/Mfg C)hl.ChC. `� CapacityJ�� LD No Compartments F PKG. TREATMENT PLT. ❑ f �r I Method of Disposal i u, Distance to nearest: Well Foundation ® Property Line .+ M-1110..& LEACHING LINE Length of lines =7otarle- th/size FILTER BED Cl Distance to nearest: we 't I Foundation * Property Line i 4 All i SEEPAGE PITS S�-Depth T Size t 3 3 Number SUMPS 1 ❑ Distance to nearest: r� `Well t Foundation Property Line ` DISPOSAL PONDS ❑ r 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#fie San Joaquin Local Health District. Home owner or licensedagent's signature certifies the following:-"I certify that in the performance of the work for which this permit is issued, I shall not employ arny 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 subjecttork a 5 ompensa- tion 'of Califor i .' I t 1 4s r The applican st call all r quire. spe ions.,Complete drawing on verse side. 7 Q Sign Title: / � � Date: ! f FDR/DEPARTMENT USE ONLY r [ Application Accepted by ' Date - t4rea Pit or rout Inspection by } I r Date Final inspection by Date I Additional Comments: IT ATr� �Or��(T7! �7(� � gr-�-D 1 P 1 1RA7/0 ❑ Stk 46f-6781 ❑ Lodi 36.9-3621 ❑�Mantec 'SM-7104 ❑ Trac 835-6385 [ I - . y b��t5 } Applicant - Return all copies to: Environmental Heaid Permit/Services 1601'E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE }AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"N0. r INFO t' A _ <n GAS/�� t eH1} (Ri 21 EV.t%.l 'a {' �.�b �' - �� S ...g •r EH 1426 1 hh