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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT J 1601 E. HAZELTON AVE., STOCKTON, CA rl c 3 Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) �I[�(� t'�TPL 11LT Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install th9Wbyyff//�1{q��d }r{,, app ication is I made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ru 6 Blll�u M�M4t San Joaquin Local Health District. Job Address �a�O f `City ---VL Lot Size PM 1 Owner's Name )�y Z, KI�E Address /A�0 I C d47;L" . 41 J ail•cr Phone 3 Contractor ^ "'CU^ Address 4 rc J. Com'` ` '�`"� License No. (,)-323Phone ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C3 SYSTEM REPAIR fY 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 ET Manteca Die.of Well Excavation -- Dia. of Wel Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other 171 Delta Depth of Grout Seal Type of Grout - "fi ation —.Approx. Depl.h I I Eastern Surface Seal Installed by Repair Work Done LT Type of Pump H.P. I�g— State Work Done *��• -`�"c' Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 51 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION I I (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: Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments _ PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line ILEACHING LINE ❑ No. 6 Length of fines Total length/size- FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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."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 persona subject to workman's compensa- tion laws of California." The applicantustt cc 11 for all re aired inspections. Complete drawing on reverse side. (i Signed 7( �Dy'�' lzti_/� �'[ttle: Date: a—d FOR DEPARTME T USE ONLV Application Accepted by Date '�f JjC�� Area O Pit or Grout Inspection by Date Final Inspection by_ r'+ Date 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 Ave., P.O. Box 2009, Stk., CA 95201 0AMOUiNTOUE AMOUNT REMITTED CKRECEIVED eV GATE PERMIT'NO. [FEE CASH. EH 13.24IREV.r/esl EH 1479