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z) 3� I APPLICATION FOR PERMIT �O`�(o Pf✓�NIA �� SAN JOAQUIN LOCAL HEALTH DISTRICT QKLC i�� GA 96013 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED / (Complete in Triplicate) L 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.. 1 Job Address 1�14 W �� ►J(��1V City�aJ��N Lot Size PM Owner's Name (W4WRAddress SJqMF__(-ke_, A'p pye_ Phone2 5' 6:1 Contractor's Name G r'SIV l �+i'(.(-- License No. Phone " TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK E�R LI DISPOSAL FLD. PROP. LINE FOUNDATION i;RfCUL U HER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casin ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other 09 Deltai;if0l KT01JDepth of Grout Seal STS RTr#,~ Type of Grout ❑ Irrigation --Approx. Depth ❑ Easter Surface Seal Installed by Repair Work Done ❑ Type of Pump M H.P.l�� 'RiAA Z State Work Done Well Destruction ❑ Well Diameter ,0Sealing Material (top 501 WN11Dt- J1>, 12 Depth 6M A1%C.WE,0_ Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of Irving 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 LINE O 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." 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, 1 shall empioy persons subject to workman's compensa- tion laws of California." The applica frust call forall required inspections. Complete drawing prV revs side. Signed X Tide: W Date: R EP,ZAMENT USE ONLY Application Accepted by / Date - Area f \Applicant or Grout InV100 Date Final Inspection by Date itional Comrrments: D - 11 �/ tk 468-6781 ❑ Lodi 388-3621 ❑ Manteca 823-7104 ❑ Tracy - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED H RECEIVED BY ►,DATE PERMIT`NO. REV.10/63► �„` O O ` 711 g -S