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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N'.).1 1p� A-,-A (Complete in Triplicate) r y Application is heteby 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 Local Health District. Jab Address Van.10, — r�s to City Lot Size PM Owner's Name 0Q_"eAMILi Address LQ, e4e , CA 9g5,41 Phone of 1Z —yz� T�, 2-- 8°1 Lk b" LCkr��, /� Ccntr3ct0r A l l lar.�1� Address $nom UI�A, �.A �Ce l#a License No.t_�7_83(0 Phone R " -1n TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT- ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 1X Arc e_ PiCZGMPjk 5 DISTANCE TO NEAREST: SEPTIC TANK 7S00 / SEWER LINES �5W __.-_ DISPOSAL FLD. AID PROP. LINE FOUNDATION >SOS! AGRICULTURE WELL>.,,J)CI!_ OTHER WELL___LIQ— PITS/SUMPS ?COQ 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS v) 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation fir Dia. of Well Casing E-1 Domestic/Private ;Gravel Pack C1 Tracy Type of Casing YV� Specifications Q f_ :"i Public �ll Other Delta Depth of Grout Seal _ Type of Grout�'OPlr1 11 Irrigation Sy.Approx. Depth I I Eastern Surface Seal Installed by ! re,ml line— Repair Work Done L3 Type of Pump M.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 V,)ae• LeVe,.5 Depth Filler Material (Below 50') 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is {� available within 200 feet.) �Y+' Installation will serve: Residence_ Commercial_ Other r4 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- 0 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 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San JOPquin 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 certifias 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 ornia� The app ant ust call for requir in ns- Complat d a in n rev rse si e\100 .[�� f Signe X Title: `1 0 Uate; ` FO EPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by . to ` Final Inspection by Q14/1. Date ,. Additional Comments: ; © Stk 466-6781 ❑ Lodr 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, Silk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. r EH13.24(REY,t i K 51 �`� EH 14-26 9&J •D 0"��3� Ile