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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT { 1601' E. HAZEL T ON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) SAS 4ryi0,a y** /0 , (:,_Z 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.,./ ~6Z5 W/ 0 swr Job Address s5l. City Lot Size . �4 /I2M5PM !� eaep r�PcA�q Owner's Name PAY6ro� Address Phone LT1A01007,tstyl 661-Contractor I� Address VO WY License No.�Z6.5 PhoE�AN XINIVW, -noo 01 TYPE OF WELL/PUMP: II NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ (fin PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Pe4WrGCM DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION ��`� AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE :.TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public n Other ❑ Delta Depth of Grout Seal -30 MAX, I r�T� _ Type of Grout I f Irrigation —_�Approx. Depth l 1 Eastern Surface Saul Installed by Repair Work Done ❑ Type of Pump H.p. State Work Done _ Well Destruction ❑ Diameter Sealing Material (top 50'1 — Depth Filler Material (Below 50'). TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is 1i available within 200 feet.) Installation will serve: Residence-7) Commercial— Other 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. ❑ p 11 r, Method of Disposal Distance to nearest: Well. Foundation Property Line s .IM LEACHING LINE ❑ No. & Length of lines '- FILTER BED ❑ Distance to nearest: Well Foundation Total length/size Property Line SEEPAGE PITS I I ----------------epth Size Number SUMPS Cl D stance 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'IJoaquin Local Health DFstrict. f Home owner or licensed agent's signature certifies the foilowin g: "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 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." i The applicant ust call for I1 re d inspections. Complete drawing on reverse side. { Signed X P Title: I! Date: 5��_-- USE ONLYApplication Accepted by I 7ARTIVIENTDate r i� Area Pit or Grout Inspection by Date Final Inspection by Date �AFI-) Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy •835-6385 i Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 a� FEE AMOUNT DUE AMOUNT REMITTEp INFO RECEIVED BY DATE PERMIT'NO. +.EH 13.24IREV-tiRN EH 14-28 !/ .®o li T 'I 2C V-7/1 0