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I i Il l APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA l Telephone 12091 466-'6781- PERMIT EXPIRES i'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 f0cal Health District. - I� Job Address GlQ 1L 7�fjS T"i City` Lot Size ?M 11 It Owner's Name .f�IT/t/1'1�Z �d�(�/1'1 Address _lc Z7�SS - li lcl i[.L2itt /Ll� LGCQng++�ye Contract Address A/. 6X 767 ars License IVo.,32;?,29 Ca Phone TYPE OF WELL/PUMP: .I NEW WELL ❑ WELL�REPPL CEMENT El DESTRUCTION El1 t yf PUMR INSTAL ATION Ch`" 5YS7r:ml-�REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER..LINES DISPOSAL FLD. PROP. LINE Il FOUNDATION AGRIC6VTUR�.,E"_,L' *,hOTHER WELL PITS/SUMPS v INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca T Dia. of Well Excavation '` _ Dia. of Well Casing O Domestic/Private ❑ Gravel Pack ❑ Tracy. Type of Casing Specifications 1:1 Public f ❑ Other ❑ Delta Depth of-Grout Seal 1 Type of Grout i❑ Irrigation Irri �A 1 g pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work pone ❑ Typeof Pump H:P. State Work Done "f Well Destruction ❑ Well Diameter Sealing Material (to�50') Depth ler Material Ieelow 501 -- --° TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAIR DDITION DESTRUCTION ❑ (No septic system permitted if public-sewer is -� 1 ai ,-- available within 200 feet.] W Installation will serve: Residence_ Commercial �� Other57 Number of living units: ".-Number o/fJ�droa}s sit..__ t 3 ! �+ N Character 9f.soil to a depth of d 3 feet: ___, a/�YLG�IIII:G t �, Water table depih SEPTIC TANK- ❑ Type/Mfg l Capacity 1 No. Compartments j _ PKG. TREATMENT PLT. ❑ - Mettod of Disposal st I Distance to nearest:- Well <' Foundation Property Line -,. / s LEACHING LINE �NO. & Length-of lines_, o��>.�'` -,Total l�ength/size : Q Y t —G p I,ILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 2' Depth a_!�_ Size--- -- Number"y.A SUMPS ❑ Distance to nearest: Well Foundation- �� Property Line DISPOSAL PONDS ❑ s - F f 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 T` 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_thiscpermit is issued, I shall employ persons subject to workman's compensa- tion laws of California." 6 The applicant must call fn all ired inspections. Complete dFawing on reverse side f i Signed �' 1 � / Title: �yV..*1 ' ~� Date:! o , FOR�PAR MENT USE QNLY� � / �� Application Accepted,by_ ` _Date_ �< , 0;it r Grout Inspection by Date ,Final Inspection IV-f a � r � fT Additional Comments: ID Stk 466-6781 ❑ Lodi 1369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant- Return all copies to:',Environmental Health Permit/Services 1601 E. Hazelton AvBox,2009,_Stk., CA-95201.K I FEE . INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE, PERMIT"NO. + EH 1324[REV.t 9 5) B. EH 1426 L`7 / —�$3 111 i