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� ` APPLICATION FOR PERMIT r SAPIVJ JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 n� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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/purnp and the Rules and Regulations of the San Joaquin } Local Health District. p r i1 I Jab Address U 7f a � � 17��Wr1-!!�F. �4,D City _ r' Lot Size "T 0 PM , Owner's Name d t7 SkpPA-r Address D 'oD T OZ o Phone Contractorf—ad !SeiE lu�c` �a/�.1�f.,P.s Address /40 .S@ 6,e• CCjvecgD License No•h1*7o0 Phone B7p- .Sa I 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 u"-- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! G E, Industrial ❑ Open Bottom G Manteca Dia. of Well Excavation !2 Oia. of Well Casing X Domestic/Private ❑ Gravel Pack , `Tracy Type of Casing ,rye— Specifications Public FI Other n Delta Depth of Grout Seal Type of Grout Irrigation _Approx. Depth I i Eastern Surface Seal Installed by AytkA 5e,1"e-F— Repair Work Done 1-1 Type of Pump -- H.P. State Work Done _ } �t r Well Destruction Well Diameter Sealing Material (top 501 E7�uT ' Depth _�0 t� �'r' Filler6Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION ; _(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. C1 :Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size s FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ SEEPAGE PITS i I Depth Size. Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 r rules and regulations of the San Joaquin Local Health Di3trict. Home owner or licensed agent's signature certifiers the following: ;+l 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 taws of California." Contractor's hiring or sub-contracting signature 7 certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall eCDL rk s compensa- tion laws of California." The applicant t call for(11 wired inspections. Complete drawing on reverse side. q Signed X Title: S l}\S4�- fa`4 t ti,Pk�C�OM v FOR DEPARTMENT USE ONLY Application Accepted by ALZ Date Area } Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: �+ ` _ El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy 835-638Ed Applicant - Return all copies to: Environmental Health PermitjServirae 1601 E. Hazelton Ave., .P.O. Box 2009, tk., CA 95201 ��. C"T v FEE INFO AMOUNT DUE AMOUNT REMITTED GASH ECEIVED 8Y DATE PERITMNO. ! .� �//_y/� r i EH ,7.21 IREY.,•n S, �-92 lqjq)o-�S '