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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT / r 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1A_ Application (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 Sen Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the Son Joaquin Local Health District. D D / l l/ �l n � LI/Jyl� ° Job Address _ ��J� � �/� Ci -�`}� . / ' 'l Lot�S¢e PM Owner's Nanle(� n YI!9 b1 s�`L,_Ll�d�/ Y��Address `L Contractor R/,arla'C.S -C/L '-/�p/}�Address l �y `/" [�/�� -License No. j�`�� ` Phone�fO TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ,SYSTEM REPAIR ❑ OTHER K,OU - opsazUl DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. ' !PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 11Manteca Die. of Well Excavation �� Dia.,of Well Casing 'Domestic/Private 11 Gravel Pack ❑ Tracy Type of Casing ��-�- V Z4TW A/ Specifications ❑ Public ❑ Other rDelta — Depth of Grout Seal Type-of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by t I Repair Work Dors ❑ Type of Pump H.P. State Work Done - ^ Well Destruction ❑ Well Diameter Sealing Melena!(fop 6011 � Depth -- t Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted 8 public sewer is I _J. available within 210 feet.) - Installation will serve: Residence_ Commercial_ Others Number of Irving units:_ Number of bedrooms r 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 ❑ Distance to nearest Well Foundation Property Line t SEEPAGE PITS ❑ Depth - size - Number f .SUMPS - 0. Distance to nearest: .Well Foundation .Property Lim— 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. 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 r certifies the following:"I certify that In the performance of the work for which this pemtit is issued,1 shall employ persona subject to workman's compensa- tion laws of California." The applican must call for all in ,i . Complete drawing on Yreverse i k ( r-..�/t�r Y Date: Sign Title: t r y UEPARTMI: T USE ONLY / Application Accepted by Date ^• AL1 / Area j I�'I. �•„ Dete�/7•�Y Pit or Grout Inspection by /''Date - TTnal Impecdon by f t Additional Comments: 3(1 i ❑ Stk 4866781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M ` Applicant- Return all copies to: Environmental Has" Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMITNO. INFO i1 Yl EH 14y24!(REV.I/BEI /S7 r o7