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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PEFlMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Hedlth 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 th?Rules and Regulations of the San Joaquin Local Health 1.strict. ��' Ib I f 1L v' % ��i� City Uik>~j— Lot Size PM Job Address•_ '/ Owner's Name/L9 `+�—/'LZ(L �clCC Addres�s /' �• �rC�J,�1�, //1(C iL�C<�q� ) Phone 1 L`• C ' Contractdc.:Cwy Address�'�_�[1C 7�i��,C'c�t` —License No,- ��'r CC Phone,l -S S �C TYPE OF WELL/PUMP: NEW WELL Li WELL REPLACEMENT O DESTRUCTION Li PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — _ DISPOSAL FLD.__— PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS —_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C Indus•rial C_7 Open Bottom U Manteca Dia. of Well Excavation__— Dia. of Well Casing ❑ Domestic!Private —,J Gravel Pack [I Tracy Type of C^-ing Speci'cations ❑ Puhlic D Other ❑ De!ta Depth of Grout Seal — ___ Type of Grout r`1 C Irrigation _—Approx, Depth ❑ Eastern Surface Seal Installed by--- Repair y —Repair Work Done D Type of Pump H.P._ State Work Done `�\ '4 Well Destruction C Weli Diameter Sealing Material(top 50') J`-' Depth— Filler Material(Below 500 — TYPE OF SEPTIC WORK: NEW INSTALLATION CI 1 REP 1ADDITION I,-, DESTRUCTION Li (No septic system permitted if public sewer is J� available within ZW f/het Installation will serve: Residence v Commercial—_/ Otherr-e Number of living units: Number of bedroom.- Character of soil to a depth of 3 feet: :� .=r_� t—r `•' " -----Water table depth SEPTIC TANK D Type/Mfg ___ / Capacity No. Compartments — PKG. TREATMENT PLT.L Method of Disposal Distance to nearest: Well.__ Foundation _ Property Line < LEACHING LINE (f''No. &Length of lines _ — Total length size S Yr -- -- r r � FILTER BED ❑ Distance to nearest: Well L_ Foundation—f� Property Line 5 __- SEEPAGE PITS C;-` re Depth �r _ �� Number l _- �/=�—Si _J; SUMPS lJ!� Distance to nearest: Weil_/!i C) Foundation Property Line - - - DISPOSAL PONDS C7 I hereby certify that I have prepared this application and tha' toe work will be done in accordance with San Joaquin county ordinances, state laws, ar:d 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." The applicant must call for all•equired inspections. Complete drawing on reverse side. c (` f L {) — JILL, Signed Title: Data: I J FOR D'E`PARTMENT USE ONLY ��f<!� / _ Date_�i L :) C Area Application Accepted by /_ '-f-----`- --- )(it or Grout Inspection by T / --=-G�Uate 1'':- --L-� Final Inspection by� '� nn/-- Date. Additional Comments: -- — ----- Stk 466-b781 ': Lodi 369-3621 C Manteca 8•'0134 Trace 835-6355 Applicant - Return all copies to: Environmental Health Permit,SP-OCac 1601 E. Hazelton Ave., P.O f.�o>< Stk., CA 95201 `EC AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED By DATE PERMIT NO. NFO — .EH 1354(aEJ.r. G' CO --i�Clo�ca EH/Laza