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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELiON 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. 10144 E. Job Address Freuc�t Lr4/'?� IAC' City k4WI« Lot Siz PM Owner's Name VAIIDA! L,/f'1 UTAe Address P"rDQ� (�Ot7�1� �G�/ rlo ��r"- h j 5 — Z�6 NICI Contractorv, • C/ fc ,{{r Address- I''1 rt` _ r License No. — Phone 13�s TYPE OF WELL/PUMN NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION�❑,/ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERP 6D/1 b0f/Ny DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WEL tt OTHER WELL PITS/SUMPSI INTENDED USE TYPE OF WELL PROBLEM AREA CONST I6CTIOfp SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Cas S6 11Domestic/Private ❑ Gravel Pack ❑ Tracy - Type of Casing Specifications ❑ Public C3 Other ❑ Delta Depth of Grout Seal Y of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surfaceeal Installed try Repair Work Done ❑ Type of Pump H.P. �St�atte Work Done . Well Destruction ❑ Well Diameter nn�-_ Sealing Material (top S0) UMlNf/ bP DAG C SOrr A4/! 11IA/ A Dep11 Y�/ f Filler Material (Below 501) TYPE OF SEPTIC WORK: Ni;W INSTALLiATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I 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 feat: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well s 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: Well 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 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 applicant ust call for all r uir i p cti s. Complete drawing on reverse side. Signed X—r Title: �--rte Date: FOR DEPARTMENT USE ONLY IC Application Accepted by iL(A�l.(� S Date-- �� Area Pit or Grout Inspection by! Date Final Inspection by Date Additional Comments: ] [L jhZ CCOIri) JAC kglfs ❑ Stk 488-6781 ❑ Lodi 389-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO /CASH ♦EH 13-24(REV 1/e sl EH 14ffi