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' APPLICATION FOR PERMIT I SAN JOAQUIN.'LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES•1 YEAR F.Ft'OM'DATE 9SSUED�'' '''e`' � ' " }` s (Complete in`Trphcatel 4 Vis, `4"` 10' 4 r t 5-_. R { " -e4 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. ,f' A,4 a r'Vr+ i•) 5-s ,Era",.` t dryer 1Q ntatr 7;'ar, v k - - Job Address Z% to " �.�':,s. "�t`�ty�bftT itF-`1- .k' t .ill Lot Size _y�1�Z.C7�7 PM j. ` Owner's"Name'r:4#_/x'-3 U S !- " Addres "s L r.1fJAa L "�x3' Contracto011.3iJukcCCr "�`�c-aa YAddress '101562,V.ekh Cyan," ' Wjcense No. -,-13y3 Phon I4 0� TYPE OF WELLIPUMP: NEW WELL❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ~ PUMP INSTALLATION ❑ SYSTEM REPAIR-0 . OTHER �.�`Law7ctl7t't.�� i.YCu 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 ❑ Manteca Dia. of Well Excavation -hSyn(AA Dia. of Well Casing ❑ Domestic/Private 1RQGravel Pack ❑ Tracy Type of Casing WC, Specifications ❑ Public ❑ Other ],- ❑ Delta "Depth of Grout Seal 10 EEC Type of Grout meW%T ❑ Irrigation QApprox. Depth ❑ Eastern Surface Seal Installed by 'r 0 Repair Work Done ❑" Type of Pump H.P. State Work Dane Well Destruction ' ❑ Well Diameter Sealing Material (top 501 `►1�Vj Morut��SxJ Depth r Filler Material fBelow.50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION.❑ DESTRUCTION ❑ (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 Character of soil to a depth of 3 feet: Water table depth r t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest. Well Foundation Property Line LEACHING LINE O No. & Length of lines -Total length/size A- " FILTER BED ❑ Distance to nearest:_ Well Foundation Property Line SEEPAGE PITS ❑ " Depth Size Number SUMPS ❑ 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 4 employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 applicaqaiust call for UrMiin=splections. Complete drawing.onn reverse side. Signed Title: �'t=�t- �t�I�' Date: 3 D ONLY r Application Accepted b Date"ll �- s hO ah •�. Pit cr Grout I s ti y D fe� F-lFinaection by_ t_ Date t Additional Comments: T ; I jj::�rt_k 466-6781 ❑ I i 369 1 C.7 Manteca 823-7104 ❑ Tracy 8355-6385 'Applicant- Return all copies to: Environmental"Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,tStk., CA 95201 FEE AMOUNT DUE�,, AMOUNT REMITTED z"CASH. —RECEIVED BY , DATE PERMIT•`NO. INFO EH 13.24(REV.7/a5) �7 ,-Vv - _ '" •l - 1 77- �f - EH 14-26 r 3s VV .lit: