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APPLICATION FOR PERMIT N JOAQUIN LOCAL HEALTH DISTRIIO 1601 E. HAZELTON 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 Rules and Regulations of the San Joaquin Local Health Distric(.� Job Address ILSL anrbar City Sbcckbm Lot Size PM Owner's Name AM ftMdr- S Cb. Address P•0. Bit 5811 r San MaIDr Ca. Phone 415-571-2434 Contractor WWM adi m Address P•0• BJK 725r 11171MhI QA License No. 376343 Phone 916-645-9355 TYPE OF WELL/PUMP: NEW WELL M WELL REPLACEMENT ❑ DESTRUCTION 11 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERMkAw DISTANCE TO NEAREST: SEPTIC TANK >50 SEWER LINES >50 DISPOSAL FLD.1_ PROP. LINE `M FOUNDATION >50 AGRICULTURE WELL >SO OTHER WELL_M— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation C1 Dia. of Well Casing N e El Domestic/Private - ❑ Gravel Pack ❑ Tracy Type of Casing `Specifications _ 1'I Public $I Other fl Delta Depth of Grout Seal 1—ll� �T9pa of Grout_b"ad Ca.._. I I Irrigation 25 Approx. Depth IMI Eastern Surface Seal Installed by IJf�J_I_IYL _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material flop 501 wat VWX Depth Filler Material lBelow 501 M TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. B Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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 Di3trict. 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, 1 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: "1 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 mL 'ss�00((,/,/yya�ll for�all tnuuired inspections. Complete drawing on reverse side. Signed % CyK Yl 0�... /�Z Title: fllo�ff_t GslaioriG Date: s Y/ r F R DEPARTMENT USE ONLY Application Accepted by —__._ - - ____- Date Area T�9 Pit or Grout Inspection by ate Final Inspection by Date 1-1 •/ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 023-7104 ❑ Tracy 835-6385 Q� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 INFO FEE AMOUNT /DUE AMOUNT REMITTED CASH REC ED BY - DATE PERMIT NO. U EN 13 24(REV.r/nbl �� T , �/ r /3 EH 14 26V D