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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) othe Application is hereby made to theSan Joaquin Local Health District for a permit to construct and/or insallth or ere is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pumpand the le in Local Health District. /I '' Job Address NQS T' �0 I c k erokeP City Lod(' Lot Size 1I PM Owner's Name (1 e W e ��r rc�d //(( Address 1 0 4J, 5, GI Ih e ro(<-ee Phone "t k(o- o'er 7 Contractor's Name V l j I A/ fe l der b 21.54-•License No. Qenl R(7 ey loiyt4 Phone q g- (3 S TYPE OF WELL/PUMP: NEW WELL 9 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 Zig ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing P 1/C Specifications ❑ Public C3 Other ❑ Delta Depth of Grout Sea— f' Type of Grout 041"10-IL❑ Irrigation 4Y_Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. tate Wprke Well Destruction ❑ Well Diameter i/ Sealing Material (top 501 y� ^'NIld-r/I XA�� 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 will to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth —Sbe Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that Irhave 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 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 applicanCj�mu�stt call for all re/q/ix�e�rf Conplate drawing onreverse side. f J / 1 signed x/�C"L�i�'y r'4 - Title: ✓1�( 7 - YC�f0 qeL) Og 1,5� Date: / FOR DEPARTMENT USE ONLY V i Application Accepted by�[ � � 1 Data � l - Area Pit 6mut Inspection Datet/ / Final Inspection bV /G Data Additional Comments: ❑ Stk 4666781 ❑ Lodi 369-3521 ❑ Ms.. BTX7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Parrrit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. a EH 1124IREV. 10/111 > -� Ll 3` oR /3 AV 9-19•x- 8s- fl�fs EH 1426