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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ' I ,L,, ,/� Job Address �Tl,4I )�/1c,,, C' `II�Yll� ;(L�7 city O t ) Lot Size PM Owner's Name Lc 0 A 10 eGI r r l at CA 4r1�Address 1`f 3 a l n `, ee es k !JZ A Pi Phone 't Contractor 1 Address o Iii dY! I n License No. Phone)l — Urn TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ LPUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE O FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t\� INTENQQD USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑.Gravel Pack 1-1 Tracy of Casing Specifications A ❑ Public - ❑ Other ❑ Delta Depth of Grou Type of Grout \V\ ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump H.P. - State Work Done I Well Destruction ❑ Well Diameter Sealing Material (top 50') j Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is / available within 200 feet.) Installation will serve: Residence_L Commercial_ Other L Number of living units: ) Numbei oi'f-jbedrooms _ Character of soil to a depth of 3 feet: '�" Pr�Px vt Water table depth SEPTIC TANK ❑ Type/Mfg T_.l,I I_ L�y�(1/-L�--� Capacity 1- T y 1, No. Compartments PKG. TREATMENT PLT. ❑ - Method of isp�sal Property Line Distance to nearest: Well Foundation_ Pro aa `l LEACHING LINE ❑ No. & Length of lines L4 /Tptal length/size— k. ength/size k. FILTER BED ❑ Distance to nearest: Well� Foundation J..,II Property Line �� SEEPAGE PITS ❑ Depth _ Size 3 Number ` SUMPS ❑ Distance to nearest: Well t,'1+ Foundation !F6' Property Line :? DISPOSAL PONDS ❑ 1 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 applicant must call forallrequired inspections. Complete drawing on reverse side.. Signed X 00 4Z//l' Title: .,�� I) 1-� Date: / - FOR DEPARTMENT USE ONLY Application Accepted by 1)1� Date Area 7 PR or Grout Inspection by L Date Final Inspection by Date ` Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca- 873-7104 ❑ Tracy 83546385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 r INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. /e + EH ia-N IREY. /es) 1 P EN 17 � .f�4M �J