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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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 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. Job Address I ✓ L `� E/L�LL r ` City � LO Size +"•'Ate' PM Owner's Name ill Rt. a A? 1f17 Address /Ir2O61 fAl-T7llsr Phone -0'14 / , 11 ' 11, l S0 n Contractor�OULIS L4EI� DB7II/n+'t Address I�9L/LS/MM FB Lcad a RLicense No. s n Phone 4 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /D/y SEWER LINES LOO DISPOSAL FLjD.1s34 PROP. LINE S© FOUNDATION LSO AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rf ❑ Industrial )'Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing - "'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 5reel— Specifications a 'L M Public ❑ Other ❑ Delta Depth of Grout Seal .-D f Type 9f Grput NL4.6 to ,• I I Irrigation —_.Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump S'u hh H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50.1 Depth Filler Material(Below 509 — TYPE OF SEPTIC WORK! NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ` SEEPAGE PITS 1 I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lam, and rules and regulations of the San Joaquin Local Health DRtrict. < 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."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 applicant musts"it for 11 raqulr d inspections. Complete drawing on reverse side. ,y Signed ).- V Title: j!� e, OAi Date: p V FOR DEPARTMENT USE ONLY .G� AppliceNo Accepted by Date �� ./ Area Pit or to u nspection by Date Final Ins)»ction by DateV Additional Comments: ❑ Stk 488-6781 ❑ Lodi 369-3621 ❑ Manteca 023-7104 ❑ Tracy 835-6305 Applicant - Return all copies to: Environmental Health Permit/Services 1501 E. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 It FEE AMOUNT DUE AMOUNT REMITTED ASH RECENED BV DATE P RMIT NO. INFO {-y,.I �[/-�n /� . EH Ill.211flEV.110 5) 05clu /)1 `� � -�70 (/ — �J EH 14a! ✓ rr//VV