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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 l PERMIT EXPIRES 11-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 Rules and Regulation_s of the San Joaquin Local Health District. Job Address zLL DV City IV-ac-(4Lot Size /x��t PM � CS1. A I ?-,Poo e&,.,P o AtPd-AL a _X LIS l' y _ Owner's Name UD coAddress Sc�� + "�0 • -t14AJ05 Phone C41TQ571-Z r ti qSb q& 3�63�15 (- b S`T Contractor IJP. 1 l k Address 1 L Ci License No. Phon TYPE OF WELL/PUMP: 7 / FWELL WE ACEMENT ❑ DESTRUCTION ❑ / EX`T1-11t-7�tJ Gt SLLf PUMP INSTALLATION ❑ SY EM REPAIR ❑ OTHER.i ZCA I/9 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ((�' ( D F UNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS INTENDED USE YPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS J ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation 12- Dia. of Well Casing ❑ Domestic/Private )Gravel Pack Tracy Type of Casing P V L Specifications t+ .* r''1 Public 'l-1 Other ❑ Delta Depth of Grout Seal .1�7. r T pe of Grout . t7 g WCLW�`�. �rl krtj�tin�n�� _.Approx. Depth I i Eastern Surface Seal Installed by 1 _ MM�4 nt epair Work Don ❑ Type o�am4i ump H.P. State Work Done_ ell Destruction ❑ Well Der Sealing Material (top 50'1 ` Depth Filler Material (Below 501 A YPE OF TIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted it public sewer is Vyy available within 200 feet.) Installation will serve. sidence Commercial_ Other Number of living units: . ber of bedrooms 3, Character of soil to a depth of 3 feet: Water table depth y i 1 I S PTIC TANK ❑ Type/Mfg Capacity No. Compartments G. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line O PAEACHING LINE ❑ No. & Length of lines Total length/size WILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth '* Size Number SUMPS L7 Distance to nearest: Well Foundation Property ' 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 Sam 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 followin - "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 lifor The applica must all for all rutrV inspecti plat raving on reverse side. Signed Title!5_!?JNb . �0 /S� � Date: FOR DEPARTMENT USE ONLY Application Accepted by �1� Date C140,70 .Araay/,91, r.rKb/ Pit or Grout Inspection by �,/ Date l Final Inspection by_ '_ 'L�{ice O C� Data Additional Comment G q L 0�" _ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-710P ❑ 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 INFO RECEIVED 8Y DATE PERMIT'NO. ♦ EH 13.24(REV,I/n 51 EH 14-26 - - C>O —