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a.° APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DAVE ISSUED S (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a Permit-,to constmct and/or install the work herein described.This application la 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. �/7 C t,' ( / / 1 Y-J) S'k _ City JtOd Q+'@ Jab Address its PM T Owner's Name ___.— Address Phare I p� a s3 LEE \A 1 A 1'T H WI.L License No. 5 i 4 , -- Phone M, Contractors Name s�$(' 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 C Industrial ❑ Open Bottom ❑Manteca Die.of Well Excavation Dia.of Well Casing ❑ Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications rq C Public ❑Other ❑ Delta Depth of Grout Seat Type of Grout rt ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal installed by vtF6 Repair Work Done O Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material(top Wi Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIDN STRUCTION❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence ) Commercial_ Other k. Number of living units:_L_ Number of bedrooms Character of soil to a depth of 3 feet: �'n to a Fr_ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity. No. Compartments Method o/Disposal PKG.TREATMENT PLT.El - _ Distance to nearest: Well_JC—)Q Foundation Property Line LEACHING LINE &f'o. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS i i 6apth Size 3 Number SUMPS ❑ Distance to nearest: Well Foundation Property line DISPOSAL PONDS ❑ r. I hereby certify that I nava prep-red this application and that the work will be dyne in accordance with Sen Joaquin county ordinances,state laws,.and rules and regulations of the San Joaquin LoCLI Health District I shall not Home owner or 4comed agent's signature certifies the following:"I certify that m the performance of the work fu•which this permit is issued, employ any person in such manner as to become subject to workman's compensation laws of California."Contractor'&hiring or sub-coitrecting 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 ap cast call r45t all n quirinspectjpns. CyDlplate drawing on reverse side. a Sig Title: Ir Date: Date:3 �� (� (FOR DEPARTMENT USE ONLY Application Accepted by Qi7C....,nw. Y Data Z- �.' �i Area I�p �� k?w Date Final Inspection by �+-'= "i Data1 Woo Pit or Grout Inspection by �=�•'�^`"� Additional Comments: --. ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 973.7104 C Tracy 83&6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009. Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By GATE PERMIT NO. INFO 'y1 /\ . EN tYN IAEV.101E7i 1 � �� _�-�� - 1 fR i&qa