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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. Job Address L ,4 rh P/O OR t1Rzn✓ aS,City 1.4 � Lot Size �134-SY r� c1 PM Owner's Name 51M r A M�Dk'p0 I Address L A,�h .5.0 P G q Phone.20% 7��Ly s 1/ ,y i.r Contractor Y ii 1`N f p��<<fhMdress Z`r Qt1 'c Yrf r/IrLn AN 4A, LUD License No.�/�fj s! Phone-u"Y `y yr 36i7 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR LI OTHER [M MGN/r4'3J? ' k.GLC 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 SPECIFICATIONS y ❑ Industrial ❑ Open Bottom R Manteca Dia. of Well Excavation 0 zr Dia. of Well Casing LI Domestic/Private KGravel Pack ❑ Tracy Type of Casing fre- Specifications f"I Public ❑ Other fl Delta Depth of Grout Seal VAr0 Ah_S Type of Grout I I Irrigation V/R01r6&_ Approx. Depth I I Eastern Surface Seal Installed by H'CLL eK P _ \ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') AIdNt Td 01,it J JU441 Depth Filler Material (Below 509 __ C TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 R{PAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) t Installation will serve: ante_ Commercial Other Number of living units: _ Num bedrooms_ ... Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK L) T 1 ype/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal N Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines _ Total length/size 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 rules and regulations of the San Joaquin Local Health Di§trict. 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: "1 certify that in the performance of the work for which this permit is issued, I shall e uI A 's compensa- tion laws of California." The applicamust call'JQjrr all required inspections. Complete drawing o reverse side. Signed X L-Z4 '� _ __- Title. / tf It l leve' FOR DEPARTMENT USE ONLY Application Accepted by _. Datefa 5,42')Area Pit or Grout Inspection by D,::.. Final Inspection by Data Additional Comments: 4W ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ^ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bo 009, Stir., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED I CK CASH RECEIVED BY DATE PERMIT NO. r EH 13-I4IREV.rin sr 7/1V C, / /) EH 142e