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t APPLICATION FOR PERMIT � meq �.v Y SAN JOAQUIN LOCAL�HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209} 4G6-6781 PERMIT EXPIRES 11YEAR FROM•DATE ISSUED• (Complete in-Triplicate) /,Q ,t,. ,F a•., *' ,..'�'. ,• ¢ ts�� •:.- y �1"0 .?t'�s � :., x �:9i�1 { C�"` �� --�f • : t 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. 3 + { .. • i:k. , l Job Address gm.'/ IN P4�7 A I.F ; Ci��`' Lot Size �' PM Owner's Name - ��] �f � Address :f - - - Phone-570-2 AO./( Contractor)j ew F r- �5s De Address_ h = License No. Phone 4S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ . DESTRUCTION ❑vPT& - PUMP INSTALLATION ❑ SYSTEM REPAIR .El OTHER 316 M'0A)1TU? DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private fX Gravel Pack ❑ Tracy Type of Casing yG Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal IV _M 141 t(Jm Type of Grout t L— 1� i ❑� Irrjga�1cZri_� ---Approx. Depth ❑ Eastern Surface Seal Installed by Cp or /1~G7`J pair one ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter 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 T 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 1 f FILTER BED ❑ Distance to nearest: Welly Foundation Property Line {� SEEPAGE PITS ❑ Depth f• - Size Number SUMPS ❑ Distance to nearest: Well ,r Foundation Propertyine"" j 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." Contractors 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 applica st all fo all req 'ed inspections. Complete drawing on reverse side. Signed X Title: 0 Date: 9 'FOR DEPARTMENT,USE ONLY Application Accepted b I PP P Y ` ''�`'"�- Date �- r�r Area Pit or Grout inspection by` ate/ Fi off IJIn�S ction"by / e Date Additional Comments: �p f�� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Peimit/Services 1601 E. Hazelton Ave., P.O. Box 2009„Stk., CA 95201 t FEE INFO AMOUNT DUE }a.AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT"N0. ..EH 13-24(REV.1/s 5) EH 14-M l {(l{