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APPLICATION FOR PERMIT 'A � ' SAN JOAO.UIN LOCAL.HEALTH DISTRICT _ � V3 SGL 1601 E. HAZELT,ON AVE.,^STOCKTON, CA n �� ` Telephone (209) 466-6781 PERMIT EXPI14ES'1 YEAR FROM DATE ISSUED n_ f, � sre..(Completein Triplicate) : , f,. `"„��[°`"`1` ,b 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 N_o: 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ,' " , Job Address 1 YGity S e Lot Size PM Owner's Name / elle T/it s 'C�i/@�� `Address !07 S_`Si y,c �g/�tN __. Phone S Contractor Address /67 4 :SSI • License No. Phone TYPE OF WE /PUMP: NEW WELL LJ WELL.IRE PLACEMENT ❑ DESTRUCTION'❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER;❑ 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 t { r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications ' ❑ Public ❑ Other s, ❑ Delta Depth of Grout Seal Type of Grout M r ❑ Irrigation --Approx. Depth l❑ Eastern Surface Seal Installed by �A 7 ; .Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') ' Depth Filler Material(Below 501 "t TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONINo septic system permitted if public sewer is i' available within 200 feet.) Installation will serve: Residence_ Commercial— Other .,r__.— —•. 9 I _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: - i Water table depth SEPTIC TANK ❑ Type/Mfg Capacity I No. Compartments— PKG. TREATMENT PLT. ❑ t l Method of Disposal _ F Distance to nearest: - Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines r l j 'Total length/size FILTER BED ❑ -Distance to nearest: Well Foundation ---= Property Line - SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Fo dation- -"°PProperty Line I 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." Contractor's hiring or sub-contracting signature certifies the followinocaor ertify 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 CalifornThe applica faH require spections. Complete drawing on reverse side. y Signed X Title: Date: PARTMENT USE ONLY Application Accepted by � f�: ,nn 0.MFl .� Date a� Area L/ U Ole y Date Final Inspection by Date ` pection b Additional Comments: �� 7 1�� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tr cy 635-6385y � �ose� r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY, DATE PERMIT'NO. .+ EH 13-24IREV.t/1151 `- i EH 14-28 Ir