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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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 Couniy Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Jab Address _!�� 42'-,� k,4!2City .l �n Lot Size PM Owner's Name � Address Phone ti w13T, � S��13 RIO Contractor 90imA - N 5 Address License No.-' �Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION L] PUMP INSTALLATION Of SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State_ Work Done �2Eo1� OF,F,C.7 Well Destruction —4-]•-] Well Diameter Sealing Material {top 501 .150l3 &.T A«� Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No 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 i SEPTIC TANK ❑ Type/Mf~g�"�- Capacity No. Compartments PKG. TREATIAENT PLT:Q ~�� Method of Disposal Distance to nearest:R.: Well Foundation Property Line LEACHING LINE 4171 No. & Length of lines i + Total length/size y •.� r 4 1 FILTER BEiU Distance to nearest: Well Foundation Property Line SEEPAGE TS ❑ Depth �ize Number �:SUMPS C Distance to nearest: ' Well Foundation Property Line (�p15 OSAL^FONDS Ch C� i'�hareb�r certifegalA'y,that I have prepared this application an ;that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and rons of the Sari Joaquin Local HealtVDistrict. Home owner ar;lit en;d-agbnt's signature certifies thV461lowing: "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 cert that, the perf ormanbj�pf the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." (n The applicant �lfor��II required inspections. Complete drawing on reverse Ae. i �� Signed � %frT`� " r �cZ� Title: �S Date: V� i F�DEPATMEIVT USE ONLY l �l 4 Application A�epted by Date Area Pit or Grout Inspection by Date Final Inspection by' Data 1 Additional Comments: ❑Stk 466-6781 U Lodi 369-3521 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE" I INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY �, '' DATE PERMIT'NO. CASH ` '> ' ` , + EH 13-7,4(REY. EH 14-26 _._ -