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\ r► . APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 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 / � City � Lot Size PM r /� Owner's Name ddress -47M i. AW-4P,0::f9 aW Phone tO Contractor 5xS�_.Address a2/oR49 UX fZ10 License No.'Ila eFle.�4P Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION W PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial F1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private .Ll Gravel Pack © Tracy Type of Casing Specifications * Public F] Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx, Depth I I Eastern Surface Seal Installed by AW Repair Work Done ❑ Type of Pump if H.P. State Work D e �tY /l>fl%�YJ� COi� Well Destruction . Well Diameter 4KA`1 Sealing Material (top 501 A Depth- I& Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is 6\ available within 200 feet.) Installation will serve: Residence_,___ Commercial— Other N j Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r " SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal, Distance to nearest: Well Foundation Property-Line *1 LEACHING LINE 3 ❑ No. & Length of lines Total length/size \ FILTER BED ❑ Distance to nearest: Well Foundation Property Line a i. .,,SEEPAGE PITS i I I Depth Size Number ' SUMPS f �. ❑ Distance to nearest: Well Foundation Property Line S _ ',.,-.-,DISPOSAL PONDS ❑ 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 persalt in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of 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 applicantrequ' ctinns. Complete drawing on evens 9 ide. i Signed X-7/y; y Title: r Date: 4 Z FORPAR�MENT-USE ONLY . t Q� Application Accepted by i.tl` 1r'�a �V ]� C LQ-f`1JlJV`w� Date Lt ✓<4"� Area' Pit or Grout Inspection by�7 Date Final Inspection by�zff- Date a� Additional Comm6nts:_ 4. t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ElTracy 835-6385 Applicant - Return all copies to: Environmental.Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ICK 4 F q AMOUNT DUE AMOUNT R MITTED. ,.CASH { ! RECEIVED BY DATE PERMIT'NO. ..EH 13-241REV.1 H5r C7 EH 14-28 e Of