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�f! ffY APPLICATION FOR PERMIT }w��NYY Jf��R/ Jj�► SAN JOAQUIN LOCAL HEALTH DISTRICT (/ 1601 E. HAZELTON AVE., STOCKTON, CA �� Telephone 12091 466-6781 S 9 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AAEq�0Ap(I� $� (Complete in Triplicate) T� Q/STS/a+��'q`. Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. TTifs 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. J' � Job Address e City �` Lot Size PM Luis Owner's Name ("3 1,4,84—eT 711S Address Phone .Lf v (' yr wy � ' Contractor's Name Wit%/«S Je1r�r/ License No'. f12T343 Z I TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ 'tDESTRUCTION ❑-t �J ' I PUMP INSTALLATION ❑ ; SYSTEM REPAIR :N k1i OTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK-, SEWER LINES .r 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 Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑_Other---- _Q Delta Depth of Grout Seale Type of Grout LJIrrigation 4 --Approx.-Depth�� Eastern Surface Seal Installed by Repair Work Done E3 Type of Pump H.P. Q State Work Done r✓L f Well Destruction ❑ Well Diameter Sealing Material (top 501 ' ` ' ' ► ",# � Depth Filler Material (Below 501 TYPE OF SEPTIC-WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will e e:- -Residences Commercial Other r Number ofliving units: r,r Numberlof bedrooms Character of soil to a,depth-bf 3 feet: * Water table depth SEPTIC,TANK r� ❑ Type/Mfg Capacity No. Compartments O PKG:TREATMENT PLT:Q'' �r� Method of Disposal C3 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS jEl Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS )❑ r� 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."ortlia."Contractors hiring or sub-contracting signature certifWS-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 California." . - , - The applicant m all for II requir ' s ' pp pec . Complete drawing on reverse side. / p Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by`� Date Area / Pit or Grout Inspection by Date Final Inspection by s ate itional Comments: S tk 466-6761 1C1Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6365 App icant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'N0. INFO CASH +EH 13-24{REV.10163) EH 14-28 ��a 0� 1Z