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APPLICATION FOR PERMIT i e , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.•HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 -�. ;..:=r ,. -„ . .�..,. .. .. vf r. n' '. 's•avi S11CGt 11'j ...p-;P fU - PERMIT EXPIRES 1 YEAR, ROM.DATE 1$SUED..vrn y°7 rt •: qu'•i - - f ./^'chi,<. tufot.(Complete in Triplicate) ^,n.•.. 1(tL” Application is hereby made to the San Joaquin Loral Health District for a permit to construct and/or instep the work herein driecrrbod.This application is made-in compliance with;San Joaquin C(,or)ty Ordinance No.S49 for sewage or No.;1S82 for wall/pump and the!Rulm and ftegulatiom of the San Joaquin Local Health District. sir +I R'*;r . v.,.,. t 2 t o r .t, ' :. it ..: +',gftit, 3iI3o • ;: ,jrrO ^'.�., a ..�1� nr -'. . r r"1 , •. :,- „ � Job Address" A f- / Cfty%1 Q.C2&�Lot Sim _ PM Owner's Name��'Ffr� STOA/� L_il Addressa. fY�'YI i.% /.�-,QO VST...—Ptwne=-�-,?7oUNl I/cnt C4/- -11 .7Contractor's Name &J V- S 1 License No. 1' G J G Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION DY. SYSTEM REPAB60- OTHER ❑ -{ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FUD. PROP. LINE _ 1 FOUNDATION'•-ai - AGRICULTUAE-WELL— �r-OTHER WELL - -PITS/SUMPS _ - -- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,❑1 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Die. of Well Casing pl Domestic/Private ❑ Gravel Pack ❑Trecy Type of Casing Specificatioro ❑ Public [D Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by oU/ Repair Work Dona l Type of Pump isu`B H.P. l State WorkDonefef L^C4V- M? w Well Destruction ❑ Well Diameter I Sealing Material (top 60) r Q Depth Filler Material(Below 609 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION,❑ DESTRUCTION O (No septic system permitted H pudic sewer is available within 200 feet.l Installation will serve: Residence_r Commercial_ Other Number of living units:_ Number of bedrooms Character of soil to a depth of 3 feet: - - - Water table depths C SEPTIC TANK ❑, Type/Mfg . . Capacity No. CdrnpartmEnts C PKG.TREATMENT PLT. L3Method of Disposal. Distance to nearest: Well, Foundation Property Line • A LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: - Well -%Foundation. Property Line SEEPAGE PITS ❑ Depth Size Number ---"��Sl1MPS;._"' -1•- -❑-iDkrance to nearest:s=ue'WeO��•��-=foundation'-+"'��Properry Line DISPOSAL PONDS • El 'rr . y._ _ 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,all rules and regulations of the San Joaquin Local Health District. - . i 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 au manner as to become subject to workman's compensation laws of California."Contractoes hiring or subcontracting signature certifies the following:' artily that in the rformance of the work for which this permit is issued,1 shall employ parsons subject to workmen's companse- tion laws of California `" •_„.,,�,ra,,,�) _ - The applicant mus c to all r uired in .ps.�Comode�+�2ra Signed Y Title: IJJ�`'_S -. Data: f _' lf�f I i •` .-ISS:% FOR DEPARTMENT USE ONLY 1 f r !!! �2 !� Application Aikeptidby r Data G A_re4 . Pit or Grout Inspectlon ter ' Final Inspection by Date Additional Comments: ❑ Stk 466-MI.. 1. ❑;Lodii,3($3821 ❑ Manteca 823-7104 -�❑i66386 iacy-83 . . i . r Applicant-lieturn all copies tii..EmnrOnmental Health Permit/Services 1801 E. Hazelton Ave-, P.O. Bax 2009, Stk., CA 98201 , 141 i FEE AMOUNT DUE" AMOUNT REMITTED CASH RECEIVED BY DATE PERMY'NO. INFO el"a.(REV 10103)