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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT MIAMSAIWMV 1601 E. HAZEL T ON AVE., STOCKTON, CA H1.1V3H "11dlId3W0WAN3 Telephone-(209) 466-6781 8861 12 8VIN PERMIT EXPIRES 1 YEAR FROM DATE ISSUE 5 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install tthatui lication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and Zes o t heSan Joaquin Local Health District. i Job Address e_ City Qb Lot Size—Z PM ! Owner's Name /A,lam! 1_ �— Address ,v 0�4^6(eM� 4/7e, f F-- Phone 00"8-7-�- 1 Contractor&cg/7 A_yyk s Address716�� CXn+ S4. �1V1" 'n1"License No. Phone S`f I-cJ7d TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. - PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fr ❑ Industrial "❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r © Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casin q'61A. Wd 4P � Specifications ? t Y Yp 9 P CC.rl1c-'rr ta-'` 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal r_ l Type of Grout�86M4R"1 k I I'lrrigation --Approx. Depth I I Eastern Surface Seal Installed by Com✓ '�" L0e!,1SlcAS Repair Work Done ❑ Type of Pump H.P. Stats Work Done— Well Destruction ❑ Well Diamet r Sealing Material (top 50') 4if�tP -7, &4-knt4 Mui,,-6am. we-ti k( Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADOITION 1 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living 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 l ` Distance to nearest: Well Foundation Propeity.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 ermit is issued,I shall employ persons subject to workman's compensa- tion laws of California." �� h `Q` of The applicant must call f all squired inspections. side. 4-Le,6C4- Signed Title:��J7 �� / - Date: DEPARTMENT USE ONLY Application Accepted by ) _ Date �y t Area Pit or Grout Inspection by Date Final Inspection by Date +�� i Additional Comments: !. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ' I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT'NO. r +.EH 13-21)REV.t i N 5) �.. , f�d �� -7 419 EH 11-28 ;7