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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} s ; Application is hereby made to the San Joaquin Loeal 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. u Lti•J r ;' r .� Job Address Yl ` (11- fi iQ ti�a :' l..'' a ,t - I ! Cityr r• r Lot Sizo' . PM . �. t0 -Owner's Name ...?^.y'��-_;g�.a��4"J .S"'_":.- Address S�� = ->I • rLf�r� Phone Ccritractor ~ -.- ys- L , -k( [t r Address 1t7.CCC 1! Li q License No. Phone � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C DESTRUCTION = PUMP INSTALLATION F SYSTEM REPAIR'C OTHER DISTANCE -TO NEAREST: SEPTIC TANK . SEWER LINES _. _ DISPOSAL FLD. PROP. LINE j FOUNDATION _ AGRICULTURE WELL .._ OTHER WELL' PITS/SUMPS _ �I r INTENDED USE t'TYPE-OF-WELL ...PROBLEM AREA—CONSTRUCTJON-SPECIFICATIONS ❑ Industrial r 7 L Open Bottom ` h+l keca � ' of -Well Excavation ❑ Domesticl Private Gravel Pack �Dla .. �: Tracy Type of Casing!. U Public ❑ Other C Delta bepth of Grout Seal L I irrigation -L—Approx. Depth C Eastern Surface Seal, Installed by Repair Work Done C Type of Pump H.P. _ State Work Done Well Destruction C Well Diameter Seafing Material (top 504---" Depth Filler Filler Material {Below 50'j Dia. of Well Casing Specifications Type of Grout_ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIWADDITION i. DESTRUCTION = (No septic system permitt available within 200 feet, I Installation will serve: Residence Commercial _ . _ Other Number of living units: _L_ Number of bedrooms a - Q Character of soil to a depth of 3 feet: ` %4-. .0t,1 Lo.2, —__.Water table depth SEPTIC TANK U Type/Mfg' P�6 �.,` `iesyl6fG�� Cepacity__ta-15A— No. Comparunents r�• PKG. TREATMENT PLT. C' Method of Dioral Distarce to nearest: • Well di_ fourdation Property Line aT 1_ LEACHING LINE _ FILTER BED ❑ No. & Length of lines �tij a Total length/size - -U-'P-Distance to nearest: Wall -�$-C) Foundation _ Progeny Lino �yC sewer is SEEPAGE PITS L.Depth .-! __ Si2e _____._.. Number _ SUMPS E Distance to nearest: Well Foundation _ Property Line _ DISPOSAL PONDS ❑ i I harnby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lays, and rules and regulations of the San Joaquin Local Health District. Horne 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 sha 1 not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sib -contracting signature certifies the following: "I certify that in the performance of the work for Mich this permit is issued, I shall eMploy persons subject to workman's compense- tlor laws of California." The applicant must call for all req ed Inspections. Complete drawing on reverse side. Signed X _ Title: iL(_e.Date: FOR DEPARTMENT USE ONLY ((( -Application Accepted by Date _�f ` Areae_/ 'p Pit or Grout Inspection by r v Data Final Inspeclion by ate l.o �Ls Additional Comments: I - ( e: ! 1 . • r '1 .. ❑ Stk 4666781 C Lodi 389$621 ❑ Manteca 823 7104 0 Tracy 835-6385 Applicant - Return ar• copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a EH 1320 IAEV.:; a EH 14 25 FFF NFO AMOUNT DUE j AMOUNT REMITTED CASH RECEIVED 6Y DATE PERMIT N0. i o-.