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APPLICATION FOR PERMIT •N--" 1, ri SAN JOA.lUIN LOCAL HEALTH DISTRICT iAWY11L 1n�0 fUPC�'r�11� 1601 E. HAZEL T ON AVE., STOCKTON, CAI Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUE vt . (Complete in Triplicate) potp (✓t Application is hereby mads to the San Joaquin Local Health District for a permit to construct,md/or instaLthe work herein descri .This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump anulee and Regulations of the San Joaquin Local Health District. �� , •�' �i� H / �/ p ,` CUJ Il r-_4,2/j +JobAddress �.W CGr•I1Pr WfnIZ r (,U ' 6.0City_ �_ Lot Size 2Z 4 c PM r l Owner's Name CI I V k _t n Lt 2 _ Address 2�?�!�� L��CI+� ?7� oncI T T7�, S Contractor's Name _ t�Qv�C.f �wcense No. 1 1 SY Z PY.one _3 7 -4 j TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION G i PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ �Q DISTANCE TO NEAREST:_SEPTIC TANK !BOO SEWER LINES f DISPOSAL FLO.y� PROP. LINEI1__(� FOUNDATION '� AGRICULTURE WELL _-- OTHER WELL`� PITS/SUMPS.,._ i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO Yr )Ondustrial 1<Open Pottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing /�C* ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing—��_� Specifications - JPOt 1 ❑ Public ❑Other ❑ Delta Depth of Grout Seal C� Typo of Grout�Sole. �i L-1Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Sr P.— Repair —Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction C Well Diameter _ Sealing erial(top 50') S Depth_ Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION i (Noseptic system permitted it public sewer is j available within 200 feet.) 1 Installation will serve: Residen,:e_ Commercial_ Other 1 Number of living unite: Number of bedrooms Character of soil to a depth of 3 feet: __ _Water table depth i SEPTIC TANK ❑ Type/Mfg _ Capacity_ No. Compartments PKG. TREATMENT PLT.L7 Method of Disposal + Distance to nearest: Well Foundation __ Property Line LEACHING LINE ❑ No. ,Length of lines _ � _ Total length/si e_ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ De;)tf- Sae Number SUMPS ❑ Distance to nearest: Well Foun Property line _ DISPOSAL FONDS ❑ I 1 I hereby certify that I have prepared this application b.A that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of rhe San Joaquin Local Health District. Home owner or licensed agb:is signature certifias the fallowing: "I certify that in the rerformance of the work for which this permit is issued, I shall not t employ any person in such ntanrn r as to become subject w workman's compensation laws of California."Contractor'- Ing or sub-contracting signature certifies the following:"I certify that i..the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California' 3 The applicant mus for all required ins ct'� pe r1S•Complete drawing on reverse side. i g Signed Title: i �Ft41 DEPARTMENT USE ONLY y/ Application Accepted by `"~�'� Date %r— y v ` Area_ T Pit or out spection by Date 7' �L Final InspocCon by —r_ Date Additional Comme-•ts: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7165 ❑ Tracy L'45-6385 Applicant- Return rll copies to: Ervironmental Health Permit/Services 1Q1 E. Hazelton Ave.. P.C. Box 2009, Stk., CA 9Ca201 s1 9 i T INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY �— DATE PERMIT'NO. j . EH ty24 IREV.10/931 I r EH tL2a cam• ��o /�5�` �Stc, ala b�Go Fi 1