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Y q� APPLICATION FOR PERMIT "* SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZELTON AVE., STOCKTON, � '`Fe ?�w Telephone ( 466-6 PERMIT EXPIRES 1 YEAR FROM DATE ISS 'Q�.cF9 MF T s f`Q i (Complete in Triplicate) Application is hereby made to the San Joaquin Local c Health District for a permit to construct and/or install the work herein de¢ribed.hhis application is made in compliance with San Joaquin County Ordinance No.549 for sewage Or No. 1862 fa well/pump and the Rules and Regulations of the San Joaquin Local Health District. �j pts E� (^ ,,(� A o s I Job Address 3 8 6 -C C r 16 F}T I'\1� IC(� city Lot size pM Owner's Name�f��a-�AN T[ s',fA Address !?SL— 3 0 ,3 Phone Contractor Address License No.2nS 7(,1 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP 1WALLA I N U^`- —'--8yy EM RE IR DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ DISPOSAL FLD. PROP. LINE "W��FOUNDATJONM-- AGRICULTURE WELL OTHER WELL PITS/SUMP _ INTENDED USE TYPE'OF+WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial - O OPO4 80ttom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing JoDomestic/Private ❑ Gravel Pact( ❑ Tracy Type of Casing Specifications A ubfc ❑ Other 1-1 Delta Depth of Grout Seal Type of Grout I I igatio. -.n —APprox--Depth-1 -Eastern•-��.-Surface-Seal-lnstalled by r epair Work4one ❑1 Type of Pump 5L� H.P. •3 $tate Work Done , Well Destruction ElWell Diameter _��- Sealing Material hopg56') •�+ �= --DaDth .--'------Fiear-MateriaHBeMw36'1-----�.• r : ' �, - + TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I ) INa septic sysferrl permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ .Commercial_ Other ( Number of living units:_ Number of bedrooms y y <, y Character of soil to a depth of 3 feet: J" I Wt Or depth ' SEPTIC TANK ❑ Type/Mfg Capacity 1 f "No`ComillaAments } PKG.TREATMENT PLT. ❑ Method of Disposal i } Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of.lines Total length/size FILTER BED ( ❑ Distance to nearest: Well Foundation Property Line ,\ l SEEPAGE PITS 1'I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line ( 1 r 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, arr rules and regulations of the San Joaquin Local Health District. } i Home owner or licensed agent's signature cert0es the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in ch manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the foaowin : 'I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's componsa tion Lewis of C i n The applicant us It fat all require ' spection , omplwv,drawing an e side. -1� _ Signed X Title: � Date: I F IRR TMENT BE ONLY Application Accepted by �E ((��_%? Date-42-1-2[ 214 Area + ^ P Ph or Grout InspaC�ti•O Dy 1 67 Date '. Final Inspection Dated 1 Additional Comments: I t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7100 ❑Tracy 8311-6385 + Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 i INFO AMOUNT DUp/-j AMOUNT REMITTED CASH RECEIVED BY C /y DATE PERMfYNO. EH 1r.14-M (J� ..EH 11N rREV.,in sr' r �I Lii i -"�