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APPLICATION FOR PERMIT .- SAN JOAO,UIN LOCAL HEALTH DISTRICT 1601 E. HAZEL-ION AVE., STOCKTON, CA Telephone 12091 466-6* PERMIT EXPIRES 1 YEAR FROM DATE ISSUED`° t"', rn 1?t11_, {Complete in Tripl.icate) 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. Job Address s le eo Izl City , O Gt K70 A Lat Size r 4 y PM Owner's Nam -14 MAAAJJ=A e_7--dadresg' VM Phone - — /,500 iM d OP/l1A S W f�T f�P 42 O iI�J C4 X d /fes Phone - II Contra-cfor Address � License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑Jy`� P \ PUMP INSTALLATION SYSTEM REPAIR,0 OTHER 0- /��' • r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION `AGRICULTURE WELL OTHER WELL PITS/SUMPS 1}} INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth 11 Eastern Surface Seal Installed by Repair Work Done Type of Pum akJOAM H.P. 4D State Work Done Well Destruction ❑ Well Diameter Sealing Material(top 50') 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 Capacity. No. Compartments PKG. TREATMENT FLT. ❑ t Method of Disposal f F Distance to nearest: Well Foundation Property Line_ 4 I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ! ❑ Distance to nearest: Well Foundation Property Line f + SEEPAGE PITS ❑ Depth ..Size' " Number ' iSUMPS ❑ Distance to nearest: Well -Foundation Property-,Line DISPOSAL PONDS ❑ 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. % i t 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 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 appli st c II r a equired inspections. Complete drawing-on v rse side. Signed Title: 0,v11 Date: / 9 FOR DEPARTMENT USE ONLY I+I f Application Accepted by �(Hc! f\c4- �Date; O Area '-Pit or Grout Inspection by -,Date r } Final Inspection by � Additional Comments:- - y1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 p licant Return all copies to: Environmental Health Permit/Services 1601 E..Hazelton Ave-, P.O. Box 20m,"Stk., CA 95201 s FEE AMOUNT DUE, AMOUNT REMITTED ,v CK# RECEIVED BY, DATE PERMIT"NO.. _. NFO" w CASH + EH 13-241REV.r/a5) �. EH 1425 t