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APPLICATION FOR PERMIT 1 f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Appdoatton is heteby made to the San Joaquin Local Health District for a permit to construct and/or insult the work herein described.This application is made in compliance with San Joaquin County Ordinance No.599 for sewage or No.1862 for well/Dump and the Rules and Regulations of the San Joaquin Local Health District. I Job Address ��+'�'S �• J"A GKTp.✓+E��//P( ,e� City MAA'TMC Lot Size '' O AL PM Owner's Name f�yC E♦/'7L2P�I" Z_vrTddress LESS 2. 6 AAE"*&/ Qp .el i'a" Phone Contiacto L. Z � Address 7-h- License No. y�7'�7rL Phone TYP£-0F.WELLMUMP:---^--NEW-WELL-a 'WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 ,, 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 ❑_Industrial ❑ Open Bottom _ ❑ Manteca _Dia. of Well Excavation Dia.%of Well Casing ❑ Domestic/Private f ❑ Gravel Pack ❑Tracy Type of Casing T Specifications F1 Public ❑ Other n Delta Depth of Grout Seal Type of Grout_. I I Inyation —Approx. Depth -I 1 Edstere s Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Gone I Well Destruction ❑ Well Diameter 'Sealing Materia)itop 509 Depth Filler Material (Below 509 W TYPE OF SEPTIC WORK: NEW INSTALLATION `9 EPAIR/ADDITION I I DESTRUCTION 1 ) INo septic system permitted if public sewer is 6 Installation will serve: Residence 40_//,,,Commercial_ Other J Number of living units: -N.rnber of bedrooms Character of soil to a depth of 3 feet: ap"l+ —Water table depth SEPTIC TANK O Type/Mfg �e - r `� L Capacity-J.'�tl Noj0isp�l PKG. TREATMENT PLT.❑ MeDistance to nearest: WW� Foundation '$O Property LEACHING LINE No.&Latgth - 0rles ? - AO Total length/sizeFILTER BED ❑ Distance to'nearest: Well fes pr Foundation +4A r PropertySEEPAGE PITS Depth �-•, Sixe �3 rNumber r'F �0 F .Property 1 SUMPS- -0 Plsiancti to nearest: Well l a3 Foundation DISPOSAL PONDS ❑ I hefeby cerdly�that 1 have prepared this application and that ifie work will be done in accordance witfi San Joaquin county ordinances,state laws, and mules and regulations of'the San Joaquin Local HealthD3trict. 14iome owner or licensed agent's signature certifies the tollowing: "1 certify that in the performance of the work for which this permit is issued, I shall not A employ any person in such manner as to become subject to workman's compensation lays_of Califomia;;ContraetpCs hiring or sub-contracting signature certifies the following:"I cam_ify that in the performance of the work for which this permit is issued, I shall employ persons subject to workmen's wmpensa- tion laws of California." \\ 1.4 Theapplicant must ca or all required insp�ecl9p/qa. Complete drawinti ori reverse side. Signewlx Title: Date: y.�, � FOR PART USE ONLY ApplPit or Grout Accepted b '/sy/�Gf�O Oaty _T Ph a Grout Inspection by Date, � Fina( Inspection M' Date Additional Comments: v ❑ Stk 468-6181 ❑ Lodi 369-3621 ❑ Manteca 023-7104 ❑ Tracy 835-SM Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95MI FEE AMOUNT DUE AMOUNT REMITTED CASH - �` 'REOEIVED BY DATE PERMIT'N0. INPO r-101 13 . ...- ,;i- . e- .— EN ICIA