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*, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete 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 or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. c Job Address C-0-yoCITe4c�*tklll fx.IDIrT*CI#17 UG- City `T'2� Lot Size kMed pM Owner's Name a �%G;S Address (SO 0 L MOA NAM#% PIrVK Phone t kLt_T c.s 19E1kwn_-5(10 %.7 S9 L(64--A'Y Latzer, / Qct(6 Contract Address RASev, ',qL 9 icense No 43983 L Phone -0 TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT 11DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 11 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLDPROP. LINE �S FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing pdw-wzl msw jAW( E-1,❑ Open Bottom Manteca Dia. of Well Excavation �Ia ❑ Domestic/Private )d Gravel Pack Tracy Type of Casing IPVL Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation Q_0__�Approx. Depth El Eastern Surface Seal Installed by NU— -M R LLA tJ Repair Work Done ❑ Type of Pump "A H.P. State Work Done Well Destruction ❑ Well Diameter az, Sealing Material (top 501 C <AAr-«4r W� Lddla 19(40w"kTt Depth 'd0 Filler Material (Below 50') MAiMtk1:gn? AQJAkLV*,L l TYP4 OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is N//6, 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: �t iter/-� ' � Water table depth �TS� 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 ❑ Depth Size Number SUMPS ❑ 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, 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 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 of laws awing on reverse side. The appllaws an California."ustfor call for II reqs ed ins ctions. Complete dr !/1� �� Signe Title:�NVIA>�lJ�kkf SPL _ Date: S a FOR DEPARTMENT USE ONLY Application Accepted b ""`�"'�� Date ��,_� W— � Area Pit or Grout Inspection b�ll[yM Date Final Inspection by aNI , Date Ca \s�` Additional Comments: ❑ 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 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT NO. INFO + EH 13-24(REV. EH 14-26 as