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APPLICATION FOR PERMIT � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Q V f sL714 �0__t p a7— I (Complete in Triplicate) Of S 3�0 •-y/ 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. Job Address WQ ,16 /?) /City 1,eA �y-� -77 Lot Size PM Owner's Name I��IJ )qw��4ddress /l[ 1!3Agowy)u Phono 33f—A4774 AW7r7P-- Rt,7-$ ContractorAddress 4Z62-16 &224--c-4-151 License No. / Phone F TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONjE PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS 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 C] Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation _-Approx. Depth Il Eastern Surface Seal Installed by _ Repair Work Dane ❑ Type of Pump / H.P. State Work Done_ IR - ry Well Destruction ❑ Well Diameter �ealing Material (top /�.-�. � / Depth _.._.._._� i! 4 Filler � Material IBelow ) QZa'650 V TYPE OF SEPTIC WORK: NEW INSTALLATION I'I REPAIR/ADDITION I I DESTRUCTION ( I (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 PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS 0 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, anc 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 nor 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 req uir ons. Complete drawing on reverse rr /e Signed )( Title: Date: FOR DEPARTMENT USE ONLY Z f Application Accepted by Date — Area _ Pit or Grout Inspectio y Date y Final Inspection by / ) Datey 9 Additional Comments: 3 14P _[4� d G t el�xedy d r,- aet-G 6'>#✓»-" I— �t O Uk". a4 1!t r" ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385—t r--Ce.! w rC L.L/)0 App4cant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95 o,10-W" dSFEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. 4/ +.EH13-241REV.IYK55 EH 1428 Z 0