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APPLICATION FOR PERMIT . SAN JOAQUIN LOCAL HEALTH DISTRICTT 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 applicatkon 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 Son Joaquin I Local Health District. �,� � /��1LiP e J�4D W r---rt ig(V tI �,( T 1 - Job Address /l. , � ! / hr �1-C^fry Lot Size 2 PM n} Owner's Name , [O'y��+ `-' L-4.� Lf Address //ar. ^�'1-•�/��,y(/�v �' �y'Phone "Contractor CQI -1C Address �V ` C40�`f Cr- License Nu..J�Phone VJZ_Z, TYPE OF WELL/PUMP: NEW WELL �// WELL REPLACEMENT El DESTRUCTION El PUMP INSTALLATION � SYSTEM REPAIR ❑ OTHER ❑ / DISTANCE TO NEAREST: SEPTIC TANK A V4 SEWER LINES DISPOSAL FLD. PROP. LINE ut/ FOUNDATION rv�-' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI N �I ❑ Ind al ❑ Open ttom ❑ Manteca Dia. of Well Excavati n Dia. of Well Casing omestic/Private ravel Pack ❑ Traccyy Type of Casing I Specifications el L (1 Public ❑ Other el Y.�lta Depth of Grout Seal ro T pe of Grout I I Irrigation / _Approx. Dep I Eastern Surface Seal Installed by <241 f Repair Work Done 17 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth 6 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is S available within 200 feet.) Q Installation will serve: Residence_ Commercial_ Other G Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth - C' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments (• PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 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, 1 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, I shall employ persons subject to workman's compensa- tion laws of California." The applican I Ifo I !/ re m pec ons. Complete drawing on r/�/+yff/�a si Signed X / •l VI Title: I // V L N/ (_ Date: •/ FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or rout nspection b ✓/` Date !/ '/ Final Inspection b Da v i Additional Comments: ❑ Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy B35-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO . EH MNIREV.rinsi I0-5 EH 14-M fl `(