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APPLICATION FOR PERMIT . a SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZE T ON 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 Ryles and Regulations of the San Joaquin LAJ E146cr- rLocal Health District. IE Job Address R+ ly61 ' f�► s City'i �� 'ACat Size ! PM Owner's Name ' fik- Address ,S W`t'`- - 110-0 S11 Phone =' �`✓' I t��nJ's ' r 41X, de 4 l i ontract r �- � � Address la.Z,11 License Nos-� , Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ t. F4, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ►� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Die.'of Well;Casing XDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Dept ❑ Eastern Surface Seal Installed by a1 1 i f d Repair Work Done ❑ Type of Pump. H.P. Z State Work Don =moi s Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer'is { available within 200 feet.) ` = Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms ` jJ, t III Character of soil to a ate tabI depth of 3 feet: I Water i p s.depth _ SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal `" t Distance to nearest: Well I Foundation Property Line µ k LEACHING LINE ❑ No. & Length of lines . - _ Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line' j SEEPAGE PITS ❑ Depth Size Number f SUMPS ❑ Distance to nearest: Well Foundation Property'Line i DISPOSAL PONDS ❑ 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 M --+- ome-owner-or-licensed-agent's signature-certifies-the-following: "I`certify that"in the perfoPmbadd-of"thetwork for whicFi'this permi "4 rules and regulations of the San Joe uin Local Health District. H -- t'is�i§sued,'I shallJnot employ any person in such manner as to become subject to workman's compensation laws of California.".Contractor's hiring or sub-contracting 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. The applicant II r all d inspections. Complete drawing,on'gev-r e'side Signed— - -.-M-..Title: :C (6' Rn 14-104 - pate: 'y aZS f R DEPARTMENT USE ONLY F - AFA `SApplication Accepted by Date Area /I . Pit or Grout Inspection by Date Final Inspection by Date d� ' 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 I� INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT"NO. F + EH 13-24 IREV.1/a 5) / F EH 14-26