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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON AVE., STOCKTON, CA Na Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 0 �)_*, ` (Complete in Triplicate) olo p� ,�„ A(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 ap_p_licaati`on 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. -Z3 76 l�.�/G .�Y_ STa1 cillo Joh Address City �LOt Size PM Owner's Name cy"2LrS �f9%S Address �'� Phone �06 71f� Contractor 1yt'f22ijd1 Address 7rWp �iiL,i"o�y �! License No. 'ZS'&'/' 7* )� Phone 6960 TYPE OF WELL/PUMP: NEW WELL ❑ 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 ,_L_Manteca...j Dia. of Well Excavation Dia. of Well Casing I-) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public 0 Other ` ❑ Delta i Depth of Grout Seal Type of Grout _ I 1 Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump I H.P.' State Work Done �1 Well Destruction ❑ Well Diameter = Sealing Material (to`p 501 Depth t Filler Material (Below 50 :x,, \V" TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION o septic system permitted if public sewer is s available within 200 feet.) i. Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: ' Water table depth M SEPTIC TANK ❑ Type/Mfg Capacity\ No. Compartments {� PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well_ Foundation Property Line s LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size _..Number SUMPS L) 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 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 or all requir i pe s. Complete drawing on reverse side. Signed X Title: fSTrd2 Date: R DEPARTMENT USE ONLY ,Application Accepted by na Date Area y Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: j ❑ 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. Bax 2009, Stk., CA 95201 CK f INFO AMOUNT DUE �jA/MOU-N`T REMITTED CASH RECEIVED BY �7 DATE Q /PERMIT'NO. +.EH14-24{flEV.i/ns1 ,�� G\ �U f� � 11 EH 14-28 •/ � V E7 .7`-�