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s 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 i (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 Rules and Regulations of the San Joaquin Local Health District. e j Job Address go Y28 74 _3-wn-lKG4 _____ City � Lot Size PM Owner's Name Address�'3k -8 1�r x �(N . Phone073-9_9B er i Contractor 1&@PAZ9UL & Atltlress/ License No. 3 LU) Phone --, WJP TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION Q- SYSTEM REPAIR 0 OTHER � k DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom . ❑ Manteca lyr Dia. of Well Excavation Dia. of Well Casing 1�Domestic/Private ❑ Gravel Pack 4s, ❑ Tracy ==:.`!r - Type of Casing T� -`- ,Specifications ❑ Public L1 Other 0 Delta Depth of Grout Seal Type of Grout I I Irrigation -- -Approx. Depth 1.1 Eastern Surface Seal installed by _ Repair Work Done Type of Pump �� H.P. ! '/ State Work Don C Well Destruction ❑ Well Diameter Sealing Material {top'50') 19 J�j_ �. Depth r Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION l ) DESTRUCTION I 1 INo septic system permitted if public sewer is CIO available within 200 feet.) r installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:j Water table depth SEPTIC TANK ❑ Type/Mfg' Capacity No. Compartments Z PKG. TREATMENT PLT. ❑ Method of Disposal 211 Distance tb nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of Iines't- 'F Total length/size FILTER BED ❑ Distance to nearest: WellFoundation Property Line SEEPAGE PITS I I Depth Size' _ Number SUMPS. ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS-, n` ❑ I hereby certify that I have prepared this'applicaiion 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 Di?;trict. " Home owner or licensed agent's signature certifies the following: "I certify th�t 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. Signed Title: fl� Lti Date:r/O R DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date ��* Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71174 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEk INFO AMOUNT DUE 1 AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. +.EH 13-24 IREV.I/N 51 3s C 170i !d�,�%_�� EH 14-26 ✓✓✓ ✓✓✓J 1 V tp