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A APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FPOM DATE ISSUED (Comr!ete in Triplicate) Appfication 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.E49 for sewage or fto.1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health Distric,�i, ' 1p Job Address '" p�._?Yn�y [ d�C/�L� City�A�N�f/ Lot Size // PM Owner's Name 1)� (�z'.- r /�.t/t�T.Address 0 �� /��JpT- ��/Phone _11/—�� Contractor/17zelw-AiS TTT Address License No. Phone 1 TYPE OF WELL/PLIMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ( 1 SYSTEM REPAIR ❑ OTHER ❑ / DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. - PROP. LINE Sjy{;q[ -FOUNDATION _�� AGRICULTURE WELL OTHER WELL PI-,S/SUMPS 't INTENDED USE YfiK TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 201ndustrial ❑ Open Bottom ❑ Manteca Dia.of Well Excavatio Dia, of Well Casing ❑ Domestic/Private ❑Gravel Pack ❑Tracy Typo of Casing- Specifications ---4-4 ❑ Public .yy❑ Other ❑ Delta Depth of Grout Seal Type of Grout / / ❑ Irrigation `5�//�Approx. Depth ❑ Eastern Surface Seal Installed by HfA/jV/,t//= f GiS� O Repair Work Done ❑ Type of Pump 3!%EL H.P. --"5 State Work Done `x) Well Destruction ❑ Well Diameter Sealing Material(top 501 J) 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 SEPTIC TANK ❑ Type/Mfg _ Capacity__ __ No. Compartments 1 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 Size Number SI!MPS O Distance to nearest: Well_ _ Foundation Property Line— DISPOSAL PONDS ❑ I I 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 �'J ! rules and regulations of the Sar•.Joaquin Local Heath District. I Hoene owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for%+Ich this permit is issued, I shall not employ any penton in such manner as to become subject to workman's compensation laws of California."Contracto/t•hiring or sub-contracting signature certifies the folldwing:"I c4rtify that in the performance of the work for which this permit is issued,I shat!employ persons subject to workmen's compensa- tion laws of California." _ The applicantm r IYrequ' ctions. Complete drawing on rQvgrse si Signed X � ti �� _ TiYe: / y/ Date: %' O OR DEPARTMENT USE ONLY 7 �1 Application cepted by x Date F1'� -L / Area Pito Grout sport on by Date�Fi al Inspection by Dates Additional Comments: 'Z�"✓ ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑Tracy 835-%485 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEESOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, INFO . EH 3-N(REV, of I- us � , '}�/ EH to2e 0 t