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Y i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE TON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) -- I 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 ' Local Health District. p� Job Address � E �� A4& l��K- city -57-0e-& i(�ot Size PM Owner's Namej -� ! ,s!�YTF iP. ddress Phone I S�. Contractor's Name icense No. 7� 9✓ Phone TYPE OF WELL/PUMP: NEW WELL ❑ SWELL REPLACEMENT 71 DESTRUCTION C]PUMP INSTALLATION &,/,/,R P,,,*4*f+STEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El industrial [J Open Bottom 1-1MantecaDia. of Well Excavation Dia. of Well Casing "Domestic/Private ❑ Gravel Pack ❑ Tracy t Type of Casing Specifications ; ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by j Repair Work Done ❑ Type of Pump 5j28 H.P. -I!Z2 State Work Done C� ,__Well Destru_ctions,,_..0 Well_Diameter_ _Sealing-Material ltop.50:1_ -(� Depth Filler Material Melow 501 TYPE:OF SEPTIC WORK:: NEW INSTALLATION ❑ REPAIR/ADDITION,❑T"DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) In allation will—serve: `Residenc lo" Gommercial_ Other i i Number of living units: Number of bedrooms f Character of soil to a depth of 3 feet: Water table depth Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Method of-Disposal- + - Distance to nearest: Well Foundation -Y Property Line LEACHING LINE ❑ No. & Length of lines Total lend6/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation s Property Line' i r DISPOSAL PONDS ❑ ` I hereby certify that I have prepared this application and that the work will be done in accordance with-Santi oaquin 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 theworkfor 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 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 must c II ora required ins ctions. Complete drawing on rreevveersr s'dd N Title: /�L— �i'"� i' � Date: Signed - FOR DEPARTMENT USE ONLY Application Accepted by �� C Date Area Pit or Grout Inspection by Date Final Inspection by Date G� 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 CASH RECEIVED BY DATE PERMIT NO. L . t + EH 13-24 TREY.101831 INFO 1T2�s;t' EH 1426