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APPLICATION FOR PERMIT ,W,1N JOAQUIN LOCAL HEALTH DISTF%,ef 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. Q Job Address '1 G L4Li ` FE n S H ) 'v wP " A J EE- ' City s c Gc 14�O k4 Size PM f J t' Q %2�U YH ST'. ! LUitE o loS- Owner's Namel"'��r �• N S '+ Address �'r L`%u STt=' N i T, X -7-7oU� pfpr4T�3 65'6-1�SS MLBA116 - 57 Contractor 1676 RISDON ROAD Addres License No. yg.r& �9 66 Phone 9 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �—' SEWER LINES 3U DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLi C3 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S (` ❑ Industrial ❑ flpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private Gravel Pack ❑ Tracy Type of Casing vL Specifications ("I Public n Other ❑ Delta Depth of Grout Seal S Type of Grout C-C'w't 1 Xl,,IVI f�r(`rgau s —Approx. Depth I I Eastern Surface Seal Installed by CoNT�14L 1�a _ c`RepJir V Gone) Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth - .7 CJI Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if pullic sewer is available within 200 feet.) I 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 LEACHING iINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certity 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 shaft 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 t13t call for a rr inspections. Complete drawing on rre rse side. / ri Signed X L Tide: S Date: /—,:t 6 rs FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7100 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BV GATE PERMIT'NO. . EH 3-21 tREV.v n sl EH 14]6