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APPLICATION FOR PERMIT q 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, n I, Job Address d/'At•�O)}�n/�'__-7IP_.�y ennne City 5-4 Lot Size d,d9 42'IL PM Owner's Name��i 7ornt�u ,er Address (�f� e __.beilo— Phone 66- 2000 T Contractor's Name Lt 4v'}V Sr,,J e f License No. 3("7-9 ZI Phone y40 21 �t-'- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 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 ❑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') (� Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION❑ DESTRUCTION❑ (No septic system permitted if public sewer is available within 200 feet.) 'l Installation will serve: Residence m Comercial_ZOther Number of living units: 40 Number of bedrooms�L Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg _._..___-- _ Capacity No.Compartments PKG.TREATMENT PLT.❑ Method of Disposal _ Distance to nearest: Well _ Foundation Property Line LEACHING LINE ❑ No.&Length of lines Total length/size FILTER BED Ll Distance to nearest: Well Foundation Property Line SEEPAGE PITS I$ Depth as Size __ Number SUMPSDistance to nearest: Well ON P Foundation 6 5 ❑ �' _..[1Property line � DISPOSAL PONDS ❑ Ivt afe,(L 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. r 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 mpaircall f I required inspections.Complete drawingo reverse ide. Signed X_1 Q'_j�j.__ Title: V 12-f 1r Data: �` O FOR DEPARTMENT USE ONLY 7 Application Accepted by '�f � DateA v Area Pit or Grout Inspection by Date Final InspaGtion by _ ate_ Additional Comments: ( :�UY� ✓L� h — 4 ❑Stk 466-6781 ❑Lodi 369-3621 ❑Manteca 823-7104 ❑Tracy 835-6.9M - ---�-- Applicant-Return all copies to:Environmental Health Permit/Services 1601 E.Hazelton Ave.,P.O.Box 2009,Stk.,CA 95201 'd [,IEI NFO �7E AMOUNT REMITTED CASH RECEIVED BV DATE PERM�TNO,EH 13.N(REV.10/83) IN 1476 -Ci• ��.> J �l 1