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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E.' HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 is PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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. Job Address w W. 1 City Lod I Lot Size PM Owner's !Name Lb A k+iro. I.OL'D. Address 142-33 6 r PhonA1-3 35-Q I Contractor Address O w— c,dvLicense No. 7 -1`SD Phon if13 TYPE OF WELL/PUMP; NEW WELL:< WELL REPLACEMENT Ef DESTRUCTION ❑ PUMP INSTALLATION ❑ " SYSTE��7M7�-,REPAIR ❑ OTHER )» Mn I for r� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __Q20' - DISPOSAL FLD. PROP. LINEOcl J FOUNDATION AGRICULTURE WELL OTHER WELL �~ PITS/SUMPS i s 1 ! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ;� ! 12 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �/ Dia. of Well Casing � ❑ Domestic/Private 9 Gravel Pack F] Tracy Tracy Type of Casin •q,�0 PV Specifications t Speccations . 0, ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 0.+ 44,Type of Grout w[ E3 Irrigation 8'!�S,�ox. Depth ❑ Eastern? Surface Seal Installed by ZnC, I ©r 1 s' Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 ! Depth Filler Material (Below 501 S TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 2DO 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. ❑ Method of Disposal }� Distance to nearest: Well` Foundation Property Line d ,i. LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property line i 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 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 must call for all requiredins �=pletdrawing on reverse side. (� Signed U5 P, �y Title: r Date:J -23-r,-7 FOR, A SE ONLY Application Accepte Date =Z x Area f� Pit Grou ton by Date Fn Inspection by Date Additional Comments: r _Zzadag or ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-631 Applican�t7- Return all copies to: EnvironmgntaI Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a �U r 2— FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT N0. INFO CASH �/ �-7 + EH137AIREV.t/e51 3(5 , 3�� IS '1 �1� J� EH raze .,li �?ZG 07 &na _