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n APPLICATION FOR PERMIT SAN JOAQUIN'LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,.STOCKTON, CA Telephone (209) 466-6781 , PERMIT EXPIRES 'I -YEAR FROM DATE ISSUED I (Complete iri 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. 5494or sewage or No. 1862 for well/pump•and the Rules and Regulations of the San Joaquin Local Health District. • ^ .� ,k ,:,, : , , 3', .Inh Andress') A �Z ! 9F, tai City /' L�yf4j- p- In t gimme fie / 'A' C PRA I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances;-,'91:to laws, and , rules and regulations of the San Joaquin Local Health District. I Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issud, I sh not r employ person -in such manner as to become subject to workman's compensation p y an y pe 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, I shall employ persons subject to workman's compensa- . tion laws of Calif rnia." The applicant u t call for a ired inspections. Complete drawing on reverse side. Signed Title: - UW1kF e_ Date: �a FOR DEPARTMENT USE ONLY `q,l x Application Accepted by < F Date u / � Area /01` Pit or Grout Inspection b Date Final pe _ / Inspection by Date Additional Comments: ❑ Stk 466-6781 O Lodi -369-3621 ❑ Manteca 823-7104 ` ❑ Tracy, 835-M' ' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 F k INFO AMOUNT DUE AMOUNT REMITTED.0 ASH RECEIVED BY DATE PERMIT' NO. +EH1}24(REV.t/a51 , J '_ lB- Roy �'%�1 EH 1428 00 i a 4e, 6 Owner's NamEPJAL. r1 Address a-2ze-9S 'SLO Phone Contractor C.© Address C/ + 6 11lerR License No."362-7 Phone19-2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT > DESTRUCTIONS 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 ❑ Open Bottom "Manteca Dia. of Well Excavation -" "yam Dia. of Well Casing X Domestic/Private AGravel Pack ❑ Tracy Type of Casing Specifications 012--'F 14-6 ❑ Public I ❑ Other ❑ Delta Depth of Grout Seal �SZi _ Type of Grout ❑ Irrigation R �Q_Approx. Depth Eastern Surface Seal Installed by_ h Repair Work Done ❑ L❑ Type of Pump �i.ILH. P. State Work none Well Destruction Well Diameter 17 Sealing Material (top 50') Depth Filler Material (Below 501 T EPTIC WORK:. NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Re Commercial _ Other Number of living units: Num bediooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Com nrtta�ts PKG. TREATMENT PLT. ❑ o6ih d of Disposal Distance to nearest: Well � dation Property Line LEACHING LINE ❑ No. & Length of linesTotal length/size FILTER BED ❑ Distance to nearest: Foundation Property Line SEEPAGE PITSt Size Number SUMPS ❑ Distance to nearest: " Well "' —Foundation_?' Property Line DIS PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances;-,'91:to laws, and , rules and regulations of the San Joaquin Local Health District. I Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issud, I sh not r employ person -in such manner as to become subject to workman's compensation p y an y pe 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, I shall employ persons subject to workman's compensa- . tion laws of Calif rnia." The applicant u t call for a ired inspections. Complete drawing on reverse side. Signed Title: - UW1kF e_ Date: �a FOR DEPARTMENT USE ONLY `q,l x Application Accepted by < F Date u / � Area /01` Pit or Grout Inspection b Date Final pe _ / Inspection by Date Additional Comments: ❑ Stk 466-6781 O Lodi -369-3621 ❑ Manteca 823-7104 ` ❑ Tracy, 835-M' ' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 F k INFO AMOUNT DUE AMOUNT REMITTED.0 ASH RECEIVED BY DATE PERMIT' NO. +EH1}24(REV.t/a51 , J '_ lB- Roy �'%�1 EH 1428 00 i a