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z -r APPLICATION FOR PERMIT 1 f � SAN JOAQUIN LOCAL HEALTH DISTRICT g , 1601 E. HAZiL ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a pemtit to construct and/or instal the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. tfi62 for well/pump and the Rules and Regulations of the Sart Joaquin Local Health District. J �- r Job Address . � �5 City LO s,,ce PM �,� ' gMA&_ Phone Owner's N me sem- - Address• I Contractor LGJy1ir Address License Na J!2/�;+ Phone TYPE OF WELL/PUMP: NEW WELL 111 / WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION Cid SYSTEM-REPAIR L7 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. _ PROP. LINE - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USES* TYPE OF-WELL -C PROB"AREA CONSTRUCTION SPECIFICATIONS ._.__---Die. of'Well,Casing OIndustrial •'°"'�""^O Open Bottom O Mani '�'Dia.'of'Welf Excavation 4Type�Uomestic/Prvate ❑ Gravel Pack ❑Tracy of Casing__ 3peciEtcations ❑ Public O Other O/Delta Depth bf Grout Seal Type of Grout ,--"—Approx.C Irrigation Approx. - , 0�r' tem S� ce Seal lr*uWed by_. Repair Work Done L./Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Searing Material(top 50 �..- Depth Filler Materiat'IBelow 50') - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION d DESTRUCTION❑ (No system permitted if public sewer is available within 200 feet.) 04 Installation will serve: Residence__— Commercial _ Other t Number of living units: Number of bedrooms { Character of soil to a depth of 3 feet:__ Water table depth 1 f Y u ♦ No. Compartments ft (` SEPTIC TANK ❑ , Type/Mfg }capacity— PKG. TREATMENT PLT.❑ 4 ti/� Method of Disposal _ Distance to nearest: Well Foundation ° Property Line _ Total length/size t LEACHING LINE O No. & Length of lines _ . ( FILTER BED ❑ Distance to nearest: Weil Founn t�:>ts Property tine SEEPAGE PITS ❑ Depth Size f Number SUMPS ❑' Distance to nearest: Well _ Foundation Property Lire A DISPOSAL PONDS ❑ 1 hereby certify that 1 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 uin Local Health.Oisuict. ! r v Home owner or lice d agent's sig ure certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any pars In such manner a to become subject to work ' compeimtian lOws Of California."Contractors hiring or sub-contracting signature certifies the fol 'ng:;'1 certify that a performer f which this permit is issued.I shalt employ persons subject to workman's compensa- tion laws of aliform, The applies t must fired ins ng i Signed �� t i FO EPARTMENT USE ONLY Application Accepted br-,7L'� Date_�yV � AreaG1Y l DPit or Grout inspection Date Final Inspection by—,_ -�— h r-e'".47 tit Additional Comments: - e ! ` lJ7' .ems Q G / U G Jr fit/ ❑ Stk 466.8761 ❑ Lodi 369-3621 Manteca ffi3'I104 ❑ Tracy 836-SM _ a i.� APWte8M l Idealth Permit/Snrvicas 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 . mewrn all uupioa to: Environmonta � aceta cvyU t CK t FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. I `/ )NFO a �I a EN 13-244REV.t%65) ` S-7- d I r EH 14.26 S o.�