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�-� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE,ION AVE., 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. c' Job Address `139 1 f-re y"cn tl C� 2 Cittyy 4c<W � Lot Size PM ` Ownei nIn Name ` Ir CA:6 1 b.'t Address Phone /} 1 0 )noZ T Contractor —r K 1'1✓ Address cel License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f_AC ,y PUMP INSTALLATION 11SYSTEM REPAIR ❑ OTHER :soS I !OOft nS DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ` FOUNDATION AGRICULTURE WELL OTHER WELL - _-PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS A — Industrial-5 pK,,-boF pen Bottom ❑ Manteca Dia. of Well Excavation Die. of Well Casing Domestic/Private Gravel Pack ❑Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal t Type of Grout � P»'} ❑ Irrigation ---Approx. Depth -❑ Eastern Surface Seal Installed by i Repair Work Done ❑' ,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 INSTAL TION ❑ REPAIR/ADDITION ❑ DESTRUCTIO ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence._ Cc ercial_ OtNr Number of living units:_ Number of bedr ms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg C acity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well F ndation Property Line LEACHING LINE -❑ No. & Length of lines - Total length/size FILTER BED ❑ Distance to nearest: Well Fou afion Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: We ' Foundation Property Line 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 lawsfand 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."Contractofs 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 appliiccayf,'�m/yst call for all r1�quired inspections. Complete drawing on reverse side. �� S ` Signed 1 Q. n. Title: _<pA j I&/Z- [FYI_.A,%-U- ( Date: Q ij I J O D TMENT USE ONLY Application Accepted? �� L Date 11 2,i ^�S Area 17— Pit or Grout Inspgcti y n Date Final Inspection by �Date _ s Additional Comments,,�Z" � CO � A ✓.0JV_4QZ EPi>r�xcJ'�s� ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Mantes 823-7104 ❑ T cy 835,638t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ( INFO FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BV DATE �n EH 3224EyW<IR .I/e51 �� J3 �GM_ \�ZIO� EH 1 ,SS 7 -