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APPLICATION FOR PERMIT ON JOAQUIN LOCAL HEALTH DISTRO 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 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. Job Address �a 1 """ City t Lot Size 33/coo54+.'f{ PM y CO- '.EfGD Alarhect� ICSR41glco wc( Owner's Name PRIC0 `PrO&AC.'13 COAddress Sltn Nlclt C I !IK!(M7 Phone D 37 _43 D le Contractor = � n• Address?Q�336� R10 �/$-�u1� �1�'License No.S8163 j Phone TYPE OF WELL/PUMP: NEW WELL Q-1,il Y.f— WELL REPLACEMENT ❑ DESTRUCTION ❑ ��AB-n.,OG�2./(•� V(, PUMP INSTALLATION ❑ W04hct' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK Nfi SEWER LINES DISPOSAL FLD. PROP. LINE f1 FOUNDATION SSSS ��.. AGRICULTURE WELL � OTHER WEL1_42n9W_ PITS/SUMPS Aft INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation�Mr1 Dia. of Well Casing �` 13 Domestic/Private ❑ Gravel Pack Tracy Type of Casingxh c/0 lIC Specifications Fl Public ❑ Other n Delta Depth of Grout Seal -,� '0�/ Type,of Grout I I Irrigation ys� tA.Approx. Depth I I Eastern Surface Seal Installed by Yd(AQ'%1 �ICAI-fU _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ -- Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ( I RLPAIR/ADDITION I I DESTRUCTION 1 I INo 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: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments T PKG. TREATMENT PLT. ❑ M ''g��J�3CC�iy Distance to nearest: Well Foundation Properniz&G_W,:..p :JV LEACHING LINE ❑ No. & Length of lines Total length/size V FILTER BED ❑ Distance to nearest: Well Foundationrii4elUI111 LouNay r U3LI 'HEALTH SERVIG_S SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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." Contractoes hiring or subcontracting 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." The applicant r(Q�J/t�c�alk(or regw d 'nspec ons. Complete drawing on reverse side. Signed X!S1[:Id,f) 7� Title:� iD alUirr Date: ly-L �,�-r FOR DEPARTM T USE ONLY VJI y's. Application Accepted by ` , Date S `�a*� /Area " 30 Pit or Grout Inspection by t Date Final Inspection by `- Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6085 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE gMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERMIT'NO. ..EH Id.N IREV.1/861 ! EN lQ11 U