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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA TelepIVX* (209) 468-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the Son Joaquin Local He"District for s permit to construct and/or install the work herein described.This application is mads in comp" re with San Joaquin County Ordinance No.649 for sewage or No.1882 for well/pump and the Rules and Regulations of the Sen Joaquin Local Health District. Job Address B 9 r�k Wof f �re�l City 5foo(461V Lot size "= �t r{ PM owner:Name L I icr t B'K ��T•(s Address lis /�6/Ve ° "' // PIN Contractor". ��l f K f f lQ t!f' Address License No. Phone 8�3� TYPE OF WELL/PUMP: NEW WELL. WELL REPLACEMENT D DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE FOUNDATION AGRICULTURE WELL OTHER WELL (PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottom D Manteca Die.of Wei Excavation 1Y Dia. of Wefl Casing Domestic/Private ❑ Gravel Pack D Tracy Type of PVC Specifications �b D Public ❑ Other D Delta Depth of Grout Seal �=a 0 Type of Grout i7 F D•Irrigation #S:Approx. Depth D Easter Surface Ssal Installed by Repair Work Done ❑ Type of Pump XP. State Work Done Well Destruction D Well Diarnneter Sealing Material(top 50) '0� t! O Depth rtS Filler Materia(Below 60) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Cl DESTRUCTION❑ (No septic system permitted if public sewer is available within 200 feet.) Installation willserve: Residence_ Commercial_ Other Number of riving units: Number of bedrooms Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compertments PKG.TREATMENT PLT. ❑ . Method of Disposal Distance to nearest: Well Foundation Property Lie Z LEACHING LIRE ❑ No. S Length of limos Total length/sae T FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Lie DISPOSAL PONDS ❑ 1 hereby cwWy that I have prepared this application and that;he work will be dons in accordance with San Joaquin county ord mwxx ,state laws,and rules and regulatiorns of the son Joaquin Local Health District: Home owner or Hameed agerrt's signature cartifiea the foiowifig:"I owlify that in the performance of the work for which this pennit is issued.I shell not employ any parson in such manner as to become subject to workman's compensation Hays of California."Contractor's hiring or sub contracting signature r»rtlfiss 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 comperes- s tion laws Of California." R The applicant cal for ON requoo drawing on reverse side. �/ /"�y Signed ' Tide:��-��-'��— t � Data: 1 4 FOR DEPARTMENT USE ONLY Apps accepted by D Area l7 Pit or Grout Inspection by /Date �4 Ahl, Final Inspection /Wditiorel Comments: /rl��6 ✓ D Stk 485.11M ❑ Lodi 3621 D Manteca 03-7104 ❑Tracy 8364185 Appkwd-Return e9 copies to: Environmental Hoeft Permit/Services 1801 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95101 FEE INFO AMOUNT DUE AMOUNT REMITTED H RECEIVED BY HATE PERMIT'NO. I , laev.mi sm Ape-.-!'�60ve6ja ��1T7 m