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A „r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL: HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r Application is he+eby 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. Job Address ) 6q 'n`I V ek 1 Z City P pow Lot Size PM Owner's Name /41041"Y -S0� Address m� Phone '-! r 83'7 Contractor a CAki-e_ Address ISo �U�y &V9 License No. 3 Ib Phone 4 �� G 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 a FOUNDATION AGRICULTURE WELL � OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well,Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth I I Eastern Surface Seal I,nstalled by �I _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ •fir Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth 30 Filler Material )Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION rV REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence__/ Commercial Other r C� Number of living units: I Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK ❑ Type/Mfg - £ L Capacity It.0o No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line f LEACHING LINE No. & Length of lines r V Total length/size 6 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS f'r . l I Depth Size Number ? SUMPS a 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑`%, f I hereby certify that I have preparedthis 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, l 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." ,E i F �` The applicant mu all for all re �instions. Complete drawing on reverse side,LAW Signed X ' Title: I�wt��e� Date: / ' /C_ %1 - } , ' -OR Df NT USS ONLY Application Accepted by - bate _�^ T Area Pit or Grout inspection by' -€ ' _ _Date.... -...,---..-"".-- Final-inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ID Manteca 823-7104 -." O Tracy.-8'35-6385- Applicant - Return all copies to: Environmental Health Permit/Services 1601'E.Hazelton Ave. P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. EH 14-26 a -EH 13241REV.tixa7 to1561963F�