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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, Tt4s 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. _t 1,, Job Address '35 N a! r ' C�wbV e-@ '-n 2 City Lpc—k t Lot Size PM Owner's Name illi n , W Address SZS1 fi s i V� � Z-QZ Phone S U 1TE B TfZP M.og TJ1 G4 Contractorti1�LlQOS % [ems Address4$2-59 Mlss1hN BLVD A License No.0 Zfa Phone+6- TYPE OF WELL/PUMP. NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ PLUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL "., OTHER WELL PITS/SUMPS INTENDED USE 'I1TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial 0 Open Bottom El Manteca Dia. of Well Excavation L Dia. of Well Casing r1 V�Gravel Pack ❑ Tracy Type of Casing 4 n -P VC C-61 40 Specifications ❑ Pubes lic 0 Other ❑ Delta Depth of Grout Seal Type of Grout nt&4'042M t' ❑ Irrigation N Approx. Depth ❑ Eastern Surface Seal Installed byPhM%'k9c-%C-%I9 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Wel! Diameter rr Sealing Material (top 501 Depth "' SO Filler Material (Below 50'1 f�� ' TYP SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCT19 (No septic system permitted if public sewer is available within 200 feet.) Installation wi rve: Residence_ Commercial_ Other Number of living un SMI Number of bedrooms r Character of soil to a dept f 3 feet: Water table depth r SEPTIC TANK ❑ Typ fg Capacity No. Compartments PKG. TREATMENT PLT. ❑.. Method of Disposal k ; Distance to neo el! Foundation Property Line f LEACHING LINE ❑'>i - en of lines Total length/size FILTER BED ❑! a to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS ❑ :Distance to nearest: Well_ Found '� Property Line - DISPOSAL DS ❑ --w-- hereby certifythat I have it pp prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and_reguiations of the San Joaquin Local Health District. Home owner or licensed agekt'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 cert that in the rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." II The applicant must r all re it insmplet rawing only side. �D Signed Title: Date: J FOR DEPARTMENT US Ly Application Accepted by '�// Date Area Pit or Grout Inspection by `T Date Final Inspection by Date Additional Comments: ❑ Stk 466-$781 11 Lodi .369.3621 ❑ Manteca 923-7104 ❑ Tracy 835-638.5 Applicant- Return all copies.to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEAM [71 UUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. n II O s EH 13-24 IAEV.1/9 51 �� EH 14-26 II c'� . Q