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44 3jj 3 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HTON AVEC, 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 Rules and Regulations of the San Joaquin Local Health District. Noizr•4'Wc,sr- Ce.aN c.,'"yL O F �12E11�A Job Address Aoui74 95 a,,rAeFcr IZ0-4-D City� � D sE=/la,, tsle--mtj Lot Size' 6 PM Owner's Name f.l s BaS VZ-t- S T2-C3lCE Address U3A-5 410C-To w�`�• �• Phone Contractor's Name IZI CMD License No. Z.Z.O Phone udr-c3�; TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE,9 ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PJ$,S/SUMPS �\ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS •K C{ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. if Well Casing ❑ Domestic/Private 0 Gravel PAFk. ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other c� ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _ApQWx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump a H.P. State Work Done p( N Well Destruction Well Diameter Sealing Material (top 501 (2 tt9 at.0-S Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: KEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is j available within 200 feet.) Installation wi e: K"idence_ Commercial_ Other Number of living ts: ' Number of bedrooms 2 Character of soil ibis depth o�3 . Water table depthSEPTIC TANK ❑" Tg Capacity No. Compartments PKG. TREATMEN-(. 'T. ❑ Method of Disposal Distance to nearest: Well undation Property Line LEACHING LINE ❑ No. & Length of lines length/size FILTER BED ❑ Distance to nearest: Well Foundation Pr Line SEEPAGE PITS 0 Depth Size Number SUMPS Q Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have pr#Ured 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 a0ent'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 ce ify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa tion la lifornia." The ap lican 'at call all ivquired inspections. Complete drawing on reverse side. Q Signed Title: 2-1&s a r A,j Ct5-W- Date: �1 FOR DEPARTMENT USE ONLY q Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by AL 1- Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0-Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazeltdn'Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT"NO. +EH1324(REV.14la3F /D f! C, ISS x/3 11_I 133 EH 1426