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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6761 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:. .,µ ;. 7 D e!^'_ LV-• Q/G 1 ,Idi- ,Tcaf-'r /oe/��j CiN� Lot Size PMJob Address Owners Name deg',ddr -' / 0/ ",ikt l ��hone D Contractor d/�� Address license No. Phone TYPE OF WELOP_UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: APTIC TANK S[W�R LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS •INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial C1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other i O Delta Depth of Grout Seal Type of Grout— C3 rout❑ Irrigation - ---Approx. Depth ❑ Eastern Surface Seal Installed by � J Repair Work Done ❑ Type of Pump 'H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 509 r / Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ INo septic system permitted if public sewer is ablewi�t1[y.�n 2D0 feet:) Installation will serve: Residence_ Commercial_" Other= `—F -�/-/ �' " / [ L- �'J•v I Number of Irving units: _ Number of bedrooms Character of soil to a depth of 3 feet: W er table depth SEPTIC TANK O Type/Mfg;r Capacity No. Compartments PKG. TREATMENT PLT. 0 a.a Method of Disposal ¢ Distance to nearest: Well Foundation -> Property Line ti t BEACHING LINE qf< No. & Length of lines , � D Total length/size v FILTER BED ❑ Distance to near :•"estWell 6741 Foundation [d' Property Line ,,SEEPAGE PITS ❑ Depthj Size Number SUMPS ❑ Distance to nearest:.•Well Foundation Property Lim E DISPOSAL PONDS ❑ 41:� 1 hereby certify that['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."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." ! 'ti' The applicant II fqp\\(��[a��L�ze4th/ed Insp Ion"'�Complete drawing on reverse side. r Signed X L1.w_X�;-n 'r r-� t r — Title: d�nr a Date: VVV��XTT I p�1 FOR DEPARTMENT USE ON Ly o Application Accepted by _ Date ` Area J 4 l * ,bry.. + J Ph or Grout Inspection-6y [ "1 Da a Final Inspection b Date Z Additional Comments: - •'"�� ❑ Stk 466-6781 ❑ Lodi 369-3621-uj% Manteca 823-7104. ❑Tracy 835- Applicant- Return all copies to: Environmemat a th Permit/Services-1�6`01E. Ha-z'elTton,�Ave., P.O. Box 2009. Stk., CA 95201 FEE " AMOUNT DUE , AMOUNT REMITTED C RECEIVED BY` DATE PERMIT-NO, NFO 11 't EN 1Y241aEV.rrasl ' n EN 1418 Nil