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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) «' UZO Zo` 33 'e1 Application is fieieby 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. 1 UP6477--l'bS 514-6 0 J V1 SIC)` fVAJ. NO, 051-- 029-- 13w-1y Job Address /VW cyl- 6gorwoT,`t- Lahr R�l,DSCity 42c�� Lot Size _ PM CA Owner's Name /U GIS�Xddfe'*Pe4t ^VArtNphon. Contractors ress_��ZS �F• fiy/2-7-7—e 67,'I icense No.,1ZZ-�68 Phone 9YIP-1 t/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER? 7V,57- - � < DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO.__. _ —V!*. 6X10 by FOUNDATION _ AGRICULTURE WELL OTHER WELL_ •44-T�'S & , nf6 TO I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS WILL. �C ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation w CJ Domestic/Private CI Gravel Pack ❑ Tracy Type of Casing .SpeciLiFatiwis f/ftL.G 0 I-I Public f1 Other ❑ Delta Depth of Grout Seal __1*P&_Qt_G MI I I irrigation Approx. Depth I I Eastern Surface Seal installed by Repair Work Done LL Type of Pump r H.P. State Work Done _ Well Destruction ❑ Well Diameter ; Sealing Material (top 50') Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I (No septic system permitted if public sewer is R available within 200 feet.) Installation will serve: Residence_,Commercial___ Other _ \ Number of living units: Numbers of bedrooms Character of soil to a depth of 3 feet: "I Water table depth SEPTIC TANK El Type/Mfg I __ Capacity No. Compartments —� PKG. TREATMENT PLT. L7 1 Method of Disposal ` Distance to nnearest: Well Foundation Property Line �{ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth _ Size Number SUMPS, Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D I 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, 1 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." t ' The applicant mu tallcl irad inspections. Complete drawing on reverse side. Signed �� ` Title: Date: F R D PARTMENT USE ONLY 9/� Application Accepted by �_. __T Date / tJ Area '�- Pit or Grout Inspection by _ Date Final Inspection b \ >rn� Date ,1 Additional Comments: ❑ Stk 466-6781 O Lodi 369-36211 O Manteca 823-7104 O Tracy 835-6385 Applicant ,Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO r EH 13-24(REV.