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APPLICATION FOR PERMIT q !J�1 l I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone(209)466-6781 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. Job Address O(7�� T��e�te ' I/'I��J Ci City.SJ s� �^L,ot'S_ize 4, 'd9 a`J�_ PM Owner's Name l.0// 10/'Y1 ICA f�/L r' Address _ 0 ref_J6 Phone 766 - 26100 �1 ( Contractor's Name 1. f l' v J S fn J L°✓� License No. 3(,39 7-1 Phone y� —��y 21 -t— TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 ❑Industrial Cl Open Bottom ❑Manteca Dia.of Well Excavation Dia.of Well Casing •Domestic/Private ❑Gravel Pack ❑Tracy Type of Casing Specifications _ ❑Public ❑Other ❑Delta Depth of Grout Seal Type of Grout ❑Irrigation ---Approx.Depth ❑Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material(top 50') U v Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION K REPAIR/ADDITION❑ DESTRUCTION❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial Le*`�Other Number of Irving units:6 Number of bedrooms 0 _ Character of soil to a depth of 3 feet:—_ Water table depth SEPTIC TANK ❑ Type/Mfg -.___- CapacityNo Compartments ID PKG.TREATMENT PLT.❑ Method of Dispose) _ Distance to nearest: Well _. Foundation__—Property Line _— LEACHING LINE ❑ No.&Length of lines Total length/size q� FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS X Depth =_ Size Number i SUMPS _. Distance to nearest: Well"n P Foundation Property Line DISPOSAL PONDS ❑ IvN ate 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,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 aDDlicant/m call f I required inspections.Complete drawing o reverse ide. ��v -2 Signed X J�YYI. Title: vLP_to yJ Date: J FOR DEPARTMENT USE ONLY Application Accepted by _� � Date Area Pit or Grout Inspection by Date 1` Final Inspection by ate Additional Comments: =/err' YLC l-7 / 14, O ❑Stk 466-6781 Lodi 369-3621 ❑Manteca 823-7104 ❑Tracy 835-M Applicant-Return all copies to:Environmental Health Permit/Services 1601 E.Hazelton Ave.,P.O.Box 2009,Stk.,CA 96201 FEE AMOUNT 0 AMOUNT REMITTED CK a RECEIVED BY DATE PERMIT NO. INFO CASH . 1RE10/831EH 13213 EH 1475