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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,,STOCKTON, CA 61 Telephone (209) 466-6781 �_ �� )_6 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED `.�'-e # , (COMPIete 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 of No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health Dtri cam ` q �� Is Q ! Job Address _`X fir-( SOr1Ll-OF I�(�d CityOeSQ942d Lot Size o- l� 2..5 PM Owner's Name ,_ �f�l !1 f\CC AddresszZ 37Phone [J Contractor g Ik-) FC1 ress /� Rj License No, 3&0 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ _ r PUMP INSTALLATION & SYSfT�E,M�R�EPAIR ❑ OTHER ❑ DISTANCE,,TO NEAREST:'.SEPTIC TANK 106LIF SEWER LINES 4)(1 DISPOSAL FLD.�PROP- LINE feu FOUNDATION _A� AGRICULTURE WELLuaLaF OTHER WELL S PITS/SUMPS �N[; INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.'of.Wel I-Excavation Dia. of Well Casing 5 iDomestic/Private Gravel Pack ❑ Tracy Type of Casing_ ; FA, Specifications f I ❑ Public ❑ Other EI Depth of Grout Seal Type of Grout yl% LlIrrigation �4pprox. De th ❑ Eastern Surface Seal Installed by - -'��y f Repair Work Done ❑ T p Type of Pump W.P. State Work Done- Well Destruction ❑ Well Diameter Sealing Material Stop 501 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 OQ I Number of living units: Number ofbedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg I r- i Capacity No. Compartments C� PKG. TREATMENT PLT. ❑ f rt J�� Method of Disposal Distance to nearest-.--Well,- Foundation Property LineA LEACHING LINE F1No. & Length of lines j Total length/size ~ FILTER BED ❑ Distance to nearest: Well Foundation j 'f Property Line SEEPAGE PITS ❑ Depth Size 'Number n SUMPS ❑k..Distance to nearest: Well Foundation— ----'Property Line A DISPOSAL PONDS 171 a �: 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. i 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 applicant call for all required inspection Complete d ing on reverse side.` Signed X lila: .n-F,A! rM 6_ _ Date: FOR DEPARTMENT USE ONLY / E Application Accepted y Date v-127� Area Pit or Grout Inspection by ' Date C Final Inspection by '...-._,_��tr[/Y✓ Date t � Additional Comments: YJ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmentai Health,Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE INFO AMOUNT DUE AM LINT REMITTED C RECEIVED BY DATE PERMIT'NO. t a EH13.241REV.iinS). EH 14-28