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F CRO4 e.0- dO APPLICATION FOR PERMIT _X P SAN JOAQU N LOCAL HEALTH DISTRICT fJl}.►'�� 1601 E. HAZE`T ON AVE., STOCKTON, GA 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 Rules and Regulations of the San Joaquin Local Health District. Job Address20 OAt, f= City 11611al Lot Size K /2 61'42w- PM Owner's Name G Address fi rr O "qq— ! 27 Contractor of L CROSS .S ,7S ___Address S License No. �. D/e�Phone..7 'x2 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Lo"' SYSTEM REPAIR L] OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK Ata SEWER LINES ND DISPOSAL FLD. AB-- PROP. LINE FOUNDATION AGRICULTURE AGRICULTURE WELL -&Q OTHER WELL&&?- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Vdustrial pen Bottom ❑ Manteca Dia. of Well Excavation y Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing C Specifications 17 Public ❑ Other ❑ Delta Depth of Grout Seal I f Irrigation I.M.,Approx. Depth 1 I Eastern Surface Seal Installed Repair Work'Done ❑ Type of Pump .Syt� H.P. 3 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW STALLATION I] REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is T� available within 200 feet.) y. Installation will serve: Residence Commercial Other Number of living units: u .ber orooms Nf bedr Character of soil to a depth of 3 feeil Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. C] f Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size Q) FILTER BED. ❑ Distance to nearest: Well Foundation Property Line n SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well foundation Property Line DISPOSAL PONDS ❑ r 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 manneuas to become subject to workman's compensation laws of California." Contractor's hiring or sub-contacting signature certifies the following: "(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 ' spections. Complete drawing on reverse side. Signed X i/s V44- q , '~ Titie: Onl7LLex Date: r FOR DEPARTMENT USE ONLY N Application Accepted by Date -- Area . Pita Grout nspection by ata aAL"�r Final Inspection b Date Additional Comments: 3 ❑ Stk 466-6781 — _' ❑ Lodi 369:3621 ` ❑ Manteca 823-7if14 D Tracy 835-6385 I 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 I CK RECEIVED BY DATE t ERMIT':NO. INFO CASH +.EH 13-24 TREY.t i h 51 + EH 14-26