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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT E`a T A r 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone 1209) 466-6761 SEP 1 3 1"1) f PERMIT EXPIRES TYEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (complete in Triplicate) PERMIT/SERVICES 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 I made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for welt/pump and the Rules and Regulations of the San Joaquin Local Health District. �� L I Jab Address 4J C) e �41�2ko&o 4-�1p City Lot Size PM Owner's Name TIOCCcm Address 1 G C�41/W �e Phone Contractor �- Address �- - License No. t Tb 'P6one il2al� 4?3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTROCTION-❑ PUMP INSTALLATION ❑ SYSTEM REPAIR,I� OTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK--S1:WER'LINES--�- •'DISPDSXL"KL-D�— PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS !' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑/Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r� Domestic/Private O Gravel Pack ❑Tracy Type of Casing Specifications c I I Public r n Other n Delta Depthof Grout Seal Type of Grout-- I rout I I Irrigation _ —Approx. Depth I I Eastern Silrtace Seal Installed by _ Repair Work Done ❑ Type of Pump s� H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 r t t Depth oZ e r Filler Material(Below 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted i1 public sewer is 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 O Type/Mfg ~ Capacity No;.Compartments PKG. TREATMENT PLT.❑ \ .. Method of Disposal Distance to nearest: v Well Foundation Property Line - LEACHING LINE ❑ No:6 Length of lines _ Total length/size '! FILTER BED ❑ Distance to nearest: Well Foundation Property Line IZI N _ I SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Lire-•-- ,DISPOSAL ine •DISPOSAL PONDS ❑ 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. f 1 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 F employ any person in such manner as to become subject-to workman's compensation laws of Califomia." Contractor's hiring,ur sub-contrabing signature certifies the R g: "1 certify that in the performance df the work for which this permit is issued,I shall employ petsons subiactdo•workmah's-compens ., 1 fico laws ofia.The spplicall for all r fired insp ions. Complete drawing on rev r side. % Signed X' ! - Tide: L.Gs.. Date: —(cX!qd I t F I iEfPPAARTME T USE ONLY - Application Accepted by J r'/ Date Area-----AC7 '_ _• I, 02 Pn or Grout Inspection by " • !Date ' Finallnspection by ' Date Additional Comments: ❑ Stk 4666781 ❑ Lodi 369-3521 ❑ Manteca 823-7104 ❑ Tracy 835-63855 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. dox 2009, Stk., CA 85201 FEE gMOVNT DUE AMOUNT REMITTED CK RECEIVED aV ,DATE PFRMIT,NO.. . ��•+*• INFO CASH - A ..EH I3NIREV.'/x5r EH 14 38 1