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I APPLICATION FOR PERMIT ^ }oZ.Z ,,. SAN JOAQUIN LOCALHEALTH DISTRICT (/ 1601 E. HAZELTON RAVE.,STOCKTON, CA Telephone (209) 466-6781 4 PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED (Complete in Triplicate) r 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 t��'V o 5,' �J 2 f l T, City' S-rK tJ '' Lot'Size -� PM Iti./A;'' LC�/uG Address 2l-�` -' R� Phone-G' Owner's Name Zf i - Contractor� y4/1I4"�4w Address f CtQ M AU V 4b&- License No-� ZS Ph,, TYPE OF WELL/PUMP: 1 I� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION le SYSTEM REPAIR ❑ OTHER ❑ O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ -0ISPOSAL'FLD. `"PROP:'L'INE FOUNDATION AGRICULTURE WELL OTHER WELL -SPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom I ❑ Manteca Di&. of Well Excavation '} :'Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing y Specifications L1 Public 1-1Other- ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation lApprox. Depth El Eastern Surface-seal Installed by rr�� Repair Work Done41 Type of Pump — H.P. 1�� State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 + r �h 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: I f Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ II 1 Method-of Disposal i r Distance to nearest: Well Foundation ' ..'Property-Line c- . LEACHING LINE ❑ No. &.Length of lines 1 .Total.length/size '- FILTER BED ❑ " Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ i Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 41 6 - - 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 c tion laws of California." �` j l The applicant u I for all requir din tions. Complete drawing on rev side. I _�• p Signed i ` iTitle: fll' R DEPARTMENT E ONLY Application Accepted by Date Area t Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 2 ❑ Stk 466-6761 ❑ Lodi 369-3621# ❑ Manteca 823-7104 ❑ Tracy 835-6385 . E Applicant- Return all copies�¢{to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 C CK IFEENFO AMOUNT DUE F, AMOUNT REMITTED H RECEIVED BY DATE PERMIT`NO. + EH 13-24 iREV.1/951 s ►"+ ZUo� EH 14-26