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• APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regul a Local Health District. Rai, n p �L � Soat{slpn Rf)l 'L. �Ij foaq rrtip�t � City �"�'"' "n Lot Size PM Job Address � .I.� J {r1�1 cc ZS own F-M PCA 1 t7GFtjQPN� ) O�"P Owner's Name C-Af.T'RR1JS Address —7��"' U n l lzrr, Sf.�• sty to 2oI o4Z0110, 5 e4 4fs Zba W6 Contractor 51 bsr.�'F`re. Ceas�df.Kh Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 9 A0fJ ITOR-'"('` 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 , ;K Industrial ftAtrl.r� 71Open Bottom El Manteca Dia. of Well Excavation �I unt�.m Dia. of Well Casing ❑ Domestic/Private (�OKGravel Pack ❑ Tracy Type of Casing pqL Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal tsk«a Type of Grout Ce ftJ ❑ Irrigation �Approx. Depth A � ❑ Eastern Surface Seal Installed by: Repair Work Done ❑ Type of Pump r_.bi4 H.P. State Work Done_ Well Destruction ❑ Well Diameter �w& Sealing Material (top 501 Depth (af��eL•E' Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Nailabptic syh te200 remettted if public sewer is avleInstallation 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/siz FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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: "1 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- tion laws o alifornia." The appli s,,c oor,all_r fired spa ions. Complete drawing�o�n rave Ide. Signed ""�^'"" Title: Date: DEP RT N, E ONLY Application Accepted by Date A Pit or Grout Inspec y S —£I�D Final Inspection b Date fs3�lo Additional Comma ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ acy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.. CA 96201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO I �' a EN 1324IREV.11851 / 3S� e u 'Ric -24 C1 EN 1426