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k APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 00 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. Job Address // I 'll A4,0//klE RD CityZ0/i/ Lot Size PM Owner's Name 00 R 7-012A TS L Address � /Zrj� A4P//NC Phone -wLAD Contractor kLl Ira aA6C r Address&Cox License No3773JPr Phone V 7tS TYPE OF WELL/PUMP: NEW WELL WELL REPLACEME DESTRUCTION El \ `a PUMP INSTALLATION �D SYSTEM REPAI -OTHER ❑ l DISTANCE TO NEAREST: SEPTIC TANK _12S SEWER LINES ''LOO DISPOSAL FLD. PROP. LINE �3CK y FOUNDATION AGRICULTURE WELL OTHER WELI_20 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing J Domestic/Private Gravel Pack ElTracy Type of Casing �'�Q G Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal SType of Grout ElIrrigation Sk_s2Approx. Depth ElEastern Surface Seal Installed by Cft i�_aACTb Repair Work Done ❑ Type of Pump C,tMUL D s H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 G rta07` N Depth Filler Material (Below 501 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 7p PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line p� LEACHING LINE ❑ No. & Length of lines Total length/size I 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 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 forallrequired inspections. Complete drawing on reverse side. Signed-aC,t�CylilA>-t+ Title: 4a-_n, ^- Date: 3-1'*3-JC a "`® FOR DEPARTMENT USE ONLY 46 Application Accepted'-4y Date ,,✓� Arr'ea'�L_/ Pit or rout lnspectloWby Dal ✓ � Final Inspection by � �- -7� Date Additional Comments'.> ❑ Stk 466-6781 l ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant Return°alQopies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE cPERMIT'NO. +EH 13-24(REV.1/85) 1 5 e �� EH 14.26 Y i