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w I� APPLICATION FOR PERMIT j SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 1 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) if Application is hereby made to the San Joaquin Local Health District for a permit to construe,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. f, CC� Job Address k� C City �) Lot Size PM 1M 33'9�USZ Owner's Name raGITC Co/»T f-6fx'aC-M Address Ta Phone Jol--54+4-7+' Contractor U Qom,}f!� Address 36 63 0 [1�1C dt - L# License No. S1�yc�_� Phone C116-631 K - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ / PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER S°iI �Cr+ [3 I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE cS FOUNDATION,;)- t AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavati-n L " Dia. of Well Casing i Domestic/Private ❑ Gravel Pack fr C1 Tracy Type of Casing No^f2 Specifications M Public /Other eo,.,A�{F ❑ Delta Depth of Grout Seal�� 3� Type of Grout I I Irrigation �W_Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump t i H.P. II State Work Done (� Well Destruction ❑ Well Diameter Sealing Material Itop 50'I i6cil-,i0k L0.,_41 -5,Uv t �� Depth 2> f2t_ Filler Material.lBelow 501 IM "1r'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT- ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I� LEACHING LINE ❑ No. & Length of lines I Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line IM SEEPAGE PITS I 1 Depth Size Number SUMPS 0 Distance to nearest: Well Foundation I`� Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accorFdance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. Home owner or licensed agent's signature certifies the following: "I certify that in the petior'mance 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 Cali r a.' I I The applicant a d inspections. Complete drawing on reverse side. Signe Title: � �lr� I �— Date: 1 -6 - 9L 9r. FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by '�-�t1� ��ate � � Final Inspection by Date 13:�4qs Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton 41e., P.O. Box 2009, Stk., CA 95201 I� FEE AMOUNT DUE AMOUNT REMITTED CASH KRECEIVED BY DATE V3- ERMIT'NO. INFO +.EH 13-24(REV.t/n5) yi p�U n00 7 EH 14-29 ii// ` IIS