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_ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELiON 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 application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. T Job Address �1yZo �� Citys_e&A Lot Size 3 PM Owner's Name 6 ' '11 D e.N dY`. sz_�7 Sp� Q P ,�r•Contractor _ _, -.__ r AddLggA, { - License-No. , on - -2 / TYPE OFWELL/P,UM1?: _ -i NEV rfWELL ❑ WELL REPLACEM NT ❑ DESTRUCTION ❑ — PUMP INSTAL - ION ❑ 9'4SYE"EPAIR ❑ OTHER ❑ p � DISTANCE To T.N 1RE5T:-SEPTCC TA4jjC ( SEWER LINES S DISPOSAL FUD. PROP. LINE FOUNDATION AGRIC}ILTURE WELL OTHER WELL PITS/SUMPS C t — 3 `'INTEND TED Iff TYPEOF WELL 'PROS ` M AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial fJ 01 ❑ Opel Bottom 16ta teca �. Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private YO,Grave4Pa'cl(,ti� iral t V Type of Casing Specifications - ❑ Public '. ❑ Othei r 'l., ' Dana _"" Depth of Grout Seal Type of Grout i .� ❑ Irrigation --Approx. epth '' {{ ETastl''em * Surface Seal Installed by Repair Work Done Q 'T.ipe of Pump H.P. State Work Don Well Destruction '❑ Well Diameter :Sealing Material (top Sol Depth 1 Filler Material(Below 50'I 1 TYPE OF SEPTIC WORK: dNSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is "�. f - available within 20D feet.) Installation Irving Refdenca_ Commercial` Other - Number of kving units: _ Number of bedro \\��tc Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK �' Type/Mf9 ` Capacity No. Compartments I'llPKG. TREATMENT PLT.❑ �.�(� a� Method of Disposal Distance to nearest: Well/�_-F"u tion _1110 if Property Line [/ LEACHING LINE 8 Length of lines �` To al length/size .l FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 ; r SEEPAGE PITS ❑ Depth Size 1. urlber / " [yam SUMPS ❑ Distance to nearest: Wail Foundation �1. ProRertyr Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and the a work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Dist 1. Home owner or licensed agent's signature certifies the following: ~ g g g: "I certify that in the performance of the work for which4his permit is issued, I shall not employ any person in such manner as to become subject to+kman's compensation laws of California."Contractor's hil sub-contracting signature certifies the following: "I certify that in the performance of theiwork for which this permit is issued,I shall employ persons subjecf'to workman's compensa- tion laws of California.`' -'{l � � The applicant must cap for a uired inspectiop,5,. om'p at draw; orW�erse side. Signed X Title: CI-i.yV7yt Date: (� (r 6QR DEPARTMENT USE ONLY -. Application Accepted by `(��NG.� `ytE. )...\f+�� \ OQ.zw./� Date Pito rout Inspection by (�1/.yt or'�pa ate Q"'o Final Inspection by A ori Da -1& 1� " Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3833621 O Manteca 823.7104 ❑ Tracy 8354385 - Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT flEMITTED CASH RECEIVED BY DATE PERMIT NO. • Ell En CK l�ailaEV.vxS� ��Z7i Yb _ 9-%l 107