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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.`:HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 _PERMIT EXPIRES-1 YEAR FROM DATE ISSUE(?P,. - r (Complete in Triplicate) j Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the�rk';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 Rales and Regulations of the San Joaquin Local Health District. 'AlJob Address /�ciLJ s1�� Y City LTi Lot SiPM L4 Owner's Name III �s Address Phone Contractor��7ilP/� 5L Address 4;?f 4e7_t!!2 /15,-/A l_"0A__"License No. 4AM6 Phone / Ar2:5 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION g?"' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION o Z r AGRICULTURE WELL OTHER WELL_ PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION f' J ❑ Industrial El Open Bottom E] Manteca Dia. of Well Excavation_ 1 // Dia. of Well CasinPV-C fJY6omestic/Private 2r Gravel Pack El Tracy Type of Casing Specifications �- IGS=I ` , ❑ Public ❑ Other ❑ Delta Depth of Grout Seal T of Grout_ ['*sTe ❑ Irrigation PZdApprox. Depth ❑ Eastern Surface Seal Installed by He Repair Work Done ❑ Type of Pump`' sv6 H.P. 1' 2V State Work Done Well Destruction El Well Diameters Sealing Material (top 501 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 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: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: i Well Foyadation 1k3perty Line DISPp AL PONDS ❑ I hereby certify that I have prepared this-appliea�.on Oid tha the work will:bar done_sit 0ccordance._with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local HealthDistribt. Homeowner 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 pbrsons subject to workman's compensa- tion 1,*s of California." The applicant t c ljofall re 'r inspections. Completk,drawing on rave side. F I Signed X Gr � — Title: '/ e�G Date: z FOR DEPARTMENT USE`ONLY ( r `- ;.. __ Application Accepted by Pit or Grout Inspection by Datp Final Inspection by, Date Additional Comments: �Ar•r- � �, ❑ Stk 466-6781 - ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy"W& 385 Applicant- Return all copies to; Environmental Health Pernut/Services 1601 E. Hazelton Ave., P.O. Box 2009, 4k., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. + EH 13-24 EH 14-281REV.1/8'5)