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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. TM's application is rnade 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. + f ,Ve84 / , �.�Job Address .4 � Lot Size PM y Owner's Name L JM 7 Address -SJl'A'L j' Phone _- Contractor/UD�1� 1�A ll 9A Address 7e o0 f kC r f r`A 411/ LV License No.191,9934 Phone 49130 r ' TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑1 _A -SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 14, FOUNDATION ' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � � ❑ Industrial -❑ Open B6tt6m "" :O.Manteca Dia- of Well Excavation -- Dia. of Well Casing -S ❑ Domestic/Private XGrave! Pack ',ff'Tracy Type of Casing A d F11 0, Specifications +"1 Public Cl Other '.f-i.Delta Depth of.Grout Seal 00- r/d O Type of Grout Al - if I I Irrigation 7 `18Approx. Depth I I Eastern Surface Seal Installed by S,A1/SEAL_ _ Repair Work Done ❑ Type of Pump _ H.P. State Work Done Well Destruction ❑``��Weil Diameter Sealing Material (top 50') _ ��'j,&itt6a✓W'a"pth Filler Material {Below 501 _. TYPE OF SEPTIC WORK: NEW INSTALIATION I'l REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) t Installation will serve: Residence Commercial_ Other ` Number of living units: Number of bedrooms v Character of soil to a depth of 3 feet: Water table depth SEPT!C TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER RED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMP'S ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I heretiy 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 Heatth District. Home owner or licensed agent's signature certifies ttte 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 ' Y performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa tionlaws of alifornia." -- The applica must call for required"ins C. ns. Complete drawing on arse side. y F , Signed X T ' Title: Date: O '}yFOR DEPARTMENT USE ONLY r Application cepted by )j Date l v Area Pit or Grout Inspection Data f VA 0 Final Inspection by Date ` Additional Comments: ❑ Stk-466-6781- ❑ Lodi X369-3621. ❑ Manteca- 823-7-1134- .-O-Tracy •835d6385 - --- _ - Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE t AMOUNT REMITTED CK RECEIVED BY 9DAATE PERMIT'NO. ..EHt3244REV.rias) -+ A EH 114.29