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-'� , .�..�.- -..4 1 APPLICATION FOR PERMIT �� 4- f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. This 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 F Local Health District. Job Address �,1 6S_d N r �� eY City Cl S Lot Size + PM yam• �} ./ /� . Owner's Name � Pr.h f .._4e. n Address [Js s Phone ��/ Contractor cTI, CAQWda�6113 Address7.2 SCLAdC_T J_Q _LicenseNo.&3C701�Phone I IqS-222 7— TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK $B`"'sE' SEWER LINES DISPOSAL FLD. PROP. LINE 'I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial *� Open Bottom ❑ Manteca Dia. of Wel! Excavation_- 1� Dia. of Well Casing (� WeDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S Teel a _ Specifications - [`l Public F1 Other 17 Delta Depth of Grout Seal _ 16,0 Type of Grout _ ` I 1 Irrigation _Approx..Depth I 1 Eastern Surface Seal Installed by Al d.4e.I",__, Repair Work Done ❑ Type of Pump H.P, State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material {Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION Il REPAIR/ADDITION f I DESTRUCTION I I (No septic system permitted if public sewer is I f available within 200 feet.) i` Installation will serve.-E-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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property'Line SEEPAGE PITS ['I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ' i 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 i rules and regulations of the San Joaquin Local Health Di?;trict. Home owner or licensed ' a ents signature certifies the following:g 9 g: "!certify that in the performance of the work for which this permit is issued, I shall net ~� employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contW:ting 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 California." Thea applicant must call for all required in PP q pec ions. Complete drawing on reverse side. I Signed X_ Of' ` Title: 244 Date: - FOR DEPARTMENT USE ONLY vv�� Application Accepted by Date �� Area Pit or Grout Inspe r y Date Final Inspectionby 4_ Dat ,/ 3 Additional Comments: �� 4o .e-- cu 1-6,o 4. u &A {�^ _ 1 ❑ 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., C&OU01FEE c INFO AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT'NO. ' 3-24 �D�. "� IV �� +��W 1[Y I �� /q 00 � -__1 37