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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ' 01k / 0-f-o-F�e Co 4 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work 6erein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rulernw ati�fbf the 5 Joaquin Local Health District. - C� '�LVOLoAC— Job Address / City 40 Lot Size © PM Owner's Name 'a rev& 'Art w i G e Address Phone •" /S 7 Contractor _c Tf� a.�s Address f_O_Q i ety_17 License ND. ?7 3( Phone33 y+ / �1 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 171 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL. FLD. -&- PROP. LINE 20 f FOUNDATION AGRICULTURE WELL �_- OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION$/ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I Dia. of Well Casing SZ Domestic/Private 'Gravel Pack ❑ Tracy Type of Casing _S''f4tSpecifications M Public f--1 Other 171 Delta Depth of Grout Seal S L Type of Grout _ I I Irrigation 7_M Approx. Depth ll Eastern SuPce Seal Installed by 1� Repair Work Done ❑ Type of Pump (a 0 H.P. State Work Done C4 k DZA<_T-0J1 Well Destruction ❑ Well Diameter -1 IV -- Sealing Material (top 501 C C tA 4 Depth _. 'Lza Filler Material (Below 501 1J TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION [ I DESTRUCTION I 1 (No septic system permitted if public sewer is Q 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 Distance to nearest: Well Foundation Property Line tC "1. 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 ❑ C� 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 1� 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 1 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 California." R The applicant must call for afl requi d inspections. Complete drawing on reverse side. ` Signed X Title: Dater 7 , FOR DEPARTMENT USE ONLY Application Accepted by 7 I� o6 4 Date Area__ Pit or Inspection by Date Final Inspection by Grou Date 7/ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE PERMIT'NO, + EH 13-24IREV.tiH51 �Qp_ �a5 � E76 D 71s-s EH 11-28 �