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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. rog �0 1 1 Job Address Pt'Or'+� S'{ac�1Y�C'Ton r>a 1 City S�tC-��un Lot Size I�°7X x.00 PM Owner's Name V`6 r—+ of SToc-�G'�an Address 'ZZ01 W. k)RSli``IA3hr% S+7-- -Phone QL -2 Contractor ' I k i IlIAI Address 1L7( Ric-acA U4� f'- License No. 7_3890 Phone lHn8 —b 13 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER IN PI eZ�QAaA_ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC TIONS q ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /X Dia. of Well Casing �4 ❑ Domestic/Private O Gravel Pack ❑ Tracy Type of Casing C Specifications ❑ Public It Other ❑ Delta Depth of Grout SealType orf Grout ❑ Irrigation (�Approx. Depth ❑ Eastern Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump AOA H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted B 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 CapacityNo. 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 SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 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."Contractoes 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 required inspections. Complete drawing on reverse side. y Signed X L��•—�-o /�`i�`— Title: ^�� J/✓zt�[,[i�� Date: — 2/ &/ 11-00, R EP (TM SE ONLY Application Acceptedby Date `2— _ Area a Pit or Grout Inspecti y Date Final Inspection bo�vl r Additional Comments: ❑ Stk 466-6781 F-1 Lodi 3633821Ll ❑ Manteca 823-7104 acyRib 6385F Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEENFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED eV DATE PERMIT N0. EH 1z.yt IREV.i/a sm S t Q �'� / EH 1426 �2.L /[_