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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.' HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 Y PERMIT EXPIRES 'I YEAR FROM DATE ISSUED a/�� (Complete in Triplicate) '' 99 � Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worl� mi ddesc_nt .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 Local Health District. �J �lI 7 DZ - 'j Job Address /C/[� � ,5 I Zf EIy/�e- City /) Lot Size �� PM " I 19Z J7 Owner's Name /��6/9y � �fress " T�[f / �/S/7�A / Phone W,117� s 9 -s Contractor "W5 Address �6^ e2 �1A Cdij"�/�icense No. / Phone TYPE OF WELL/PUMP: NEW WELL, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION,d/ SYSTEM REPAIR. ❑ OTHEP ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.1c2e2--�PROP. LINE FOUNDATION AGRICULTURE WELL f OTNER.,WELL PITS/SUMPS INTENDED USE TYPE OF WELL'_PROBLEMAR EA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca _Dia. of Well Excavation � '' pia. of Well Casing 3bDomestic/Private ravel Pack ►_ ❑ Tracy ; Type o Gasing ,,-�'�.� Specifications O Public ❑ Otper } ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation (:PM Approx. Depth,;-` Eastern /y ace Seal Installed by I Repair Work Done ❑ Type of Pump H.P. State Work Done ! Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material IBelow 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/AUDITION ❑ DESTRUCTION ❑ (No 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 der;16, SEPTIC TANK ❑ Type/Mfg ` Capacity No.{Compartments PKG. TREATMENT PLT. El ? �'1 Method of Disposal Distance to neare§t: Well Foundation Property Line 1; LEACHING LINE ❑ No. & Length!of lines c-'�':� Total length/size-.- FILTER BED ❑ Distance to nearest: iWell F uridation Property Lie SEEPAGE PITS ❑ Depth ' `' Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 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 rules and regulations of the San Joaquin Lo�al Health District. } Home owner or licensed agent's signature certifies-the-foHowirig: ")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.sulbject to workman's-compensation`laws of California."Contractor's hiring or sub-contracting signature certifies the following: '9 certify that in the performance of,the work`for-which th_is,permit is issued,-Lshall eM�Ioj persons subject to workman's compensa- tion laws of California." i ''� .� '1 The applicant r require i ctions,Tomplete drd{wing on r e. t Signed Title: Date: /Z 1 _ FOR DEPARTMENT USE ONLY I i t pplication Accepted by " — " -Date- 4 Area 2Y y �� .�.... ..s.�. • .- J- K 4=�. Fay.. - �_ Pit or Grout Inspection Date Final Inspection Date=� f Additional Comments: a� ❑ 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 INFO 1 AMrO+U[NTT DUE AMOUNT�REMITTED CASH 1 RECEIVED BY DATE PERMIT NO. + EH 13.24411 t/e5} t0 ! EH 1426 1 ✓ lf 1 1