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APPLICATION FOR PERMIT Id Ejih SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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.TMs 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. �L"'/'y" " ` �w Job Address 11921. �Er �• r� —yCity Lot Size ,1 PM Owner's Name t�i[>.t.1y1£. I,� 4OL-1 Address I i 9_Z 10- OV�� t� �T`�116 . ff Phone L. Contiactom A5 �1.11L�P Address K License No. Phone 7¢�f' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 8011 ❑ Industrial Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing ,❑ Domeslic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications fl Public ❑ Other fl Delta Depth of Grout Seal Type of Grout -F_ I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by a LJL Repair Work Done ❑ Type of Pump H.P. t State Work Done yy�_g 9 • f „ Well Destruction �' Well Diameter Sealing Material (top 501 Depth Filler Material l6elow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 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 FT ' 4th •r Character 6f soil to a depth of 3 feet: f 1 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ } y{: -a }Method of Disposal Distance to nearest: Well Foundation.. l Property Line f 4,jr�..- LEACHING LINE ❑., No. &Length of lines Total length/size- `FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth Size r Number ` ` °` —SUMPS.-, Ll 'Distance to-Wrest: 111%ell-' Formdation Propatry Line" DISPOSAL PONDS ❑ •f• " I hereby certify that 1 have prepared this applicaubn and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations the San Joaquin-Local Health D13trict. --- - -- . •- Home owner or licensed agent's signature certifies the following: "I certify that in-the performance of the-vitork 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 cert:/ at 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 must equired inspections. Complete drawing on reverse side. Signed X ` '>• Tkle:•'. '•9"�t ',M1' ;\ + s Date: -or-_ 7— +�.•k _+� L� x 'FOR DEPPA.RTMENT USE ONLY Application Accepted hu Date r`syJN1^,t Date ��V�'1 1 Area I T '/ Pit or Grout Inspection ii Date Final Inspection by �"�' Date/`__ 1_.�6 Additional Comments: LC) f! ❑ Stk 488-6781 ❑ Lodi 369-3621 ❑ Menta 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY GATE P!_ 5 NFO l •.EN It td IREV.i r x w '� C o1 � �-yL � �/4