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" Y APPLICATION FOR PERMIT f`0JdC+ 310-01t.01 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {2091 466-6781 PERMIT EXPIRES TYEAR 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 Count Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, f `, f C t Job Address gzo3 � r es-r f m sJ�. Cit rA-CA, Lot Size PM �1 f �J /�� j ,i �t41n�t"az1't Owner's Name nowd Address 605 N. C.+"-�cf` �✓1Vd 4(0IVZ Phone ChD Contractor aT A_L Address_3U33 Ft_1 T25U ��'- License No.C57 SS49-75Phone '411.0 (0,39-MIC, TYPE OF WELL/PUMP: NEW WELLX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ industrial ❑ Open Bottom El Manteca Dia. of Well Excavation MDia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing SGPT 40 Specifications n Public Other W PtCrULC7 F] Delta Depth of Grout Seal `%,f, Type of Grout [ema-*"r I I Irrigation —-Approx. Depth I I Eastern Surface Seal Installed by W A:bh 0* Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 50') &OAJ oict 64y Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms �}�S Character of soil to a depth of 3 feet: Water table depth �f" SEPTIC TANK ❑ Type/Mfg Capacity 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: Weil Foundation Property Line SEEPAGE PITS I 1 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 agents 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 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 call foor�all required nspectians. Complete drawing on reverse side. Signed f [�-' Title: Q/JQe�- `rocs -al( Date: —-!�!_-j i — FOR DEPARTMENT USE ONLY �f Application Accepted by QWe ' Area Pitr thou Inspection by Date /O x 'Y' r ginal Inspection by AaC4,vl Date �� Additional Comments: is z—�+ f�7�—j 4d( }L AP ,❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE [AMOUNT REMITT D CK RECEIVED BY DATE PERMIT-NO. +.EH 3-24(REV.tiN51 EH 1428