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APPLICATION FOR PERMIT --v SAN JOAQUIN LOCAL HEALTH DISTRICT L 1601 E. HAZEL T ON AVE., STOCKTON, CA a Telephone (2091 4613-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDlay (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 app on 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 Jo In Local Health District, Job Address $C0 F Ff+C•Ht,Ul�ti( !Z K trtrEM4 ROA,CD _ Ci l—Oflt Lot Size PM Owner's Name 00(AU LFtS G t LAddress 31 ilc) iZljA { A-Ul . C-057A M F57f L Phone Contractor 1 F cc." Address1� f1,�ISC3Lja Dn, lhAtz f l i ense No. Phone.�4r} 71 +DU TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM RE AIR F-) OTHER C1DISTANGE TO NEAREST: SEPTIC TANK SEWER LINES ��FS VLLp- PROP. LINE FOUNDATION AGRICULTURE WELL OOTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTI N SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ MaMeca Dia. of Well E cavation _ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casinc 2 PUG SpecificationsNCIT� ❑ Public ❑ Other ❑ Delta Depth of Grout Seal -- Type of Grout (j r'r IC} ❑ irrigation _--Approx. Depth 0 Eastern Surface Seal Installed by P ORA-tlbN DRI L4 I A16 S ICF 4 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50' t Depth Filler Material(Below 50' F TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESRUCTION 0 (No septic system permitted if public sewer 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: Watir table depth SEPTIC TANK ❑ Type/Mfg Capaci No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well: Foundation Property Line LEACHING LINE ❑ No. & Length of lines r 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 El b I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,sfate=laws,-and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the folEowing:'9 certify that in the Ferformance 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, 1 shall employ persons subject to workman's compensa- tion laws of California." �` The applican MW call for all rreequir� i sped us.Car., to drawing on reverse side Signed X itle• C Yu u' �� Z f T _ �r 5 Date: LT SE ONLY Application Accepted b �n Date _�r2_ �_ Area � fr Pit or Grout Inspec iorY� — "~ Y to 7"'�'-�� Fnal,lq-pection by,.-� � e2 Date —,57— Additional SAdditional Comme s: 0 Stk 466-6781 ' Lodi 369,-3621 ❑ Ma 7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelt n Ave., P.0- Box `,Stk., CA 95201 FEE AM Ery OUNT DUE AMOUNT REMITTED CAH RECEIVED BY DATE PER IT;NO.- +2 2a(REV.� �i�,� INFO en :4 26