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r � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE ON AVE., STOCKTON, CA 4 Telephone (209) 466-6781 PERMIT EXPIRES '!'YEAR FROM DATE ISSUED (Complete in Triplicate) i 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 l Local Health District. Job Address siT "V 7— /'T!Wf/ ` City ��t�� Lot Size . ZA 47 PM r. [! d Owner's Name S r�el a 4 dd Aress 500 S �L/.Sd j r�Orr�� Phone �ti„PQ 52I� :� '• � Contractor f/r"Rdds a 00Q/�° &4657S-40/License No jWld2j-? Phone 30— TYPE-OF WELL/PUMP:_ -------NEW WELL. f�4- -� WELL REPLACEMENT O .DESTRUCTION ❑_ _� _,;-- , �W PUMP INSTALLATIONUd�4 SYSTEM REPAIR] t OTHER C1 ' 0 �/',� /� a DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /DO-'� DISPOSAL FLO.�d AZ PROP."PNE 4 FOUNDATION AGRICULTURE WELL OTHER WELL � PITS/SUII�IPS`" ��:_> ,•; 4• T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- ❑`Industrial BTpen Bottom ❑ Manteca Dia. of Well Excavation Z49 Dia.'of'Well Casino A-Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing �-!B et, Specifications ❑ Public F1 Other Cl Delta Depth of Grout Seal e 'AL Type of Gra'utQad �E'A1r�tI I I Irrigation OWApprox. Depth l I Eastern Surface Seal Installed by 7r-yZ14[1- Z1471- z, Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material !Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION €1 REPAIR/ADDITION LI DESTRUCTION I 1 INo septic system permitted if public sewer is I 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 i Capacity No. Compartments 4\, PKG. TREATMENT PLT. ❑ �� Method of Disposal N Distance to nearest: Well Foundation Property Line :LEACHING LINE ❑ No. & Length of lines_ Total length/site FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS > � I 1 Depth Size _ Number SUMPS :- '•❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS p'', _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,'arid 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 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 must call for all required inspections\Complete drawing on reverse side. 01 Signed X Title:=_, sr— �LrJ>rs� Dater«�� FOR DEPARTMENT USE ONLY t Application Accepted by U lyl ' Date 3—w—i Area Pit or Grout Inspection by DateoQ Final Inspection by Date i Additional Comment : 'La �sJ '� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE �A¢�MYOUNT REMITTED CASH RECEIVED BY DATE PERMIT NQ + EH 13-241REV.�in51 �� o6 A* leJ- QQ EH 14-26 11 f' V-1 7