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APPLICATION FOR PERMIT s SAN JOAQUIN LOCAL HEALTH DISTRICT ._ 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application it heisbv made to the San Joaquin Local Hasith District for a permit to construct and!or install the work heroin described, This application is made in compliance with Sen Joaqum' ounty Ordinance No. 549 for sewage or No. 1862 for wetupump and in&YRulas anti Regulations of the San Joaquin Local Health District. I ��•t(' Job Addressat Sia Plot Owner's NameslkO 1—Li Address OLO'y _ ` TOSS L��'TI'hone`t l�P � �7I r 45-ZI �ianl L'afi7�ait3 y _ R Z 0 f Contractor t.�Q�b�ft mOT I Adare$$73Z33 Frrz Ccl��, License No.y�JL41-7-1 Phone lei TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT i 1 DESTRUCTION La PUMP INSTALLATION I i SYSTEM REPAIR ❑ OTHFR ❑ DISTANCE TO NEAREST; SEPTIC TANK ,,. SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION. AGRICULTURE WELL .. OTHER WELL PITSISUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTAUCTIO_N SPECIFICATIONS G Industrial G Open Bottom (� Manteca Dia. of wail Exetion pia, of Well Casing M Domestiv Private Gravel P ,T ack racy Type of Casing JG Specifications 1'1 Public I:. Other I i ) Delta Depth at Grout Seel E I t° Type of Grout (!QM4_ &AU01` I I Irrigation Approx. Depth I I Eastorn Surface Seal installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter _ Scaling Material stop 50*1 l✓" Depth _ j Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION i I IMPAER:ADDITION , I DESTRUCTION i I INO soutic system permitted if public sower is available within 206 feet.) Installation will serve: Residence# Commercial.__• Oliver Number of living units:. Numbor of bedrooms I Character of soil to a depth of 3 feet: Y Water table depth SEPTIC TANK ❑ Type/Mfg _ CapacityNo. Compartments PKG, TREATMENT PLT,0 Method of Disposal Distance to nearest: well Foundation. Property Line— f LEACHING LINE f 1 Na, 8 Length of lines . , Total length/size (� FILTER BED U Distance to nearest: Well Foundation Property Line_ SEEPAGE PITS I I Depth _. Size _�.T__ _,_, - Number SUMPS U Distance to nearest: Well_. Foundation _ Property Line _ DISPOSAL PONDS 0 —f-heraby ae'rtitjthai I have�preparad this application and that the work will l)e dons in accordance with San Joaquin county ordinances. state laws, and rules and regulations of the San Joagtiin Local Health Datrici. HOMO owner Or licensed agent'a signature certifies the following: 111 certify that in the performance of the work for which this.permit is issued, I shalt not 21 employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or sub,-contracting signature— cartifies the following: I"I certify that in the performance of the work(Or which this permit is issued,1 Shap em tion taws of California.. p Oy persons subject to workman's comoensa• The applicant must call for all _eduired inspections. Complete drawing on rover"sidp- Signed X ct�( J Title,, Rata: FOR DEPARTMENT USE ONLY Application Accepted by Date gree a . Pit or Grout inspection by Dara 5L Fina speetioR b �Q Data Additional Comments: t C) SO 488.6781 ❑ Lodi 369.3521 O Maniacs EM-7104 ❑ Tracy 835.8385 Applicant • Return all copies to: Environmentat Health Permii/Services 1801 E. Hazelton Ave.. P.O. Ba,2069, Stk., CA 95261 FEE AMOUNT BUE AMOUNT ItEINITTED x a INFO rr E H ECElVED 9V OAYEPERMIT'NO. . EH 1]• {REV.r.e� EN 14-264