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APPLfCATION FOR PERMIT s - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT�EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) j 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 k 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..* � — ► t 3 B Job Address L(=:TS 1 s $ tot 'EL '?ty�k L tSLA4 (!;%?MX City SCT0CKTd1\J Lot Size In 60.95 PM Owner's NameOCA 0-MA EJ3U_MI_%& Address PhoneZ_I7�o S555 I Contractor YLEIi-sELzim Address ig75 E 5-[Qt_it'T&Z License No. PhoneM 0 TYPE OF WELL/PUMP: NEW WELL 6Y WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION'❑ SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE-TO NEAREST: SEPTIC TANK- SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing 'IM14 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing SO-A. QVC. Specifications r4p.iblit (flpufft VN Q VOther R 'F1 Delta Depth of Grout Seal S Type of Grout _5 I Irrigation 1)J - 40-Approx. Depth I,1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H,P. State Work Done_ Well Destruction 71 Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 = TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence Commercial_ Other` Number of living units: Number of bedrooms Character of soil to a depth"of 3 feet - T Water table depth j SEPTIC,TANK ❑_ Type/MfgCapacity f, w 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 4 + SEEPAGE PITS I I Depth Size Number SUMPS 0 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 Joaquin 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 I 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 st 11 f al a uir specti omplete drawing on reverse side. Signed _ Title: STprf 6wwei/4E7 Date: i FOR"DEPARTMENT USE ONLY I `. Application Accepted by Date (� Area C t Pit or Grout Inspection by Date Final Inspection Date 0 Additional Comments: �+ov�d w17 Go+�d+-Y�a�. tLe_.r_+�� Www. 14brif ❑ Stk 466-6781 - ❑ Loi 369-3621 ❑ Manteca a23-7104 . ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 r k F' FEE INFO AMOUNT DUE AMOUNT REMITTED" RECEIVED 9Y DATE PERMIT*NO. tASIT +.EH 1x-2t(REV.t/ 5l (� EH 144-26