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APPLICATION FOR PERMIT , 'r 'SAN JOAQUIN LOCAL HEALTH DISTRv,_T 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED (Complete in Triplicate) FApplication 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 F, Local Health District, LAO Job Address FWO P84 CA l L Kl e- City L-L,t4[M Lot Size PM k Owner's Name FV vtlf'1'I wfo►- (LM Address T QPQ W 4eJf*�A�f_ Lt ude,) Phone ConQuza-r- �A�Jie_,Address W/-/, �lt� �✓ License No. S7 I � Phone 13 �' ,- TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION D PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO• PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS C. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _. i ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing V' V Specifications f4#01)X •�� t"} Public 171 Other F1 Delta Depth of Grout Seal Type of Grout _, + fy9arrigation 530 .Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done �❑ Type of Pump + Lu6L— N.P. } _.., State Work Done,ffiP1LePtt .rLucl� r� } Well Destruction ❑ . Well Diameter Sealing Material Itop 501 �^ Depth.' Filler Material [Below 501 tr�� r•1 TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAtRIADDITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial__ Other 1 I Number of living units: Number of bedrooms Character of soil to a depth of 3 f t: Water table depth SEPTIC TANK ❑ Type/M\ton Capacity - No. Compartments (r PKG. TREATMENT PLT. ❑ Method of Disposal t Distancst: Well Foundation Property.l_ine LEACHING LINE ❑ No. & Length of lies Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation I Property:Line ` SEEPAGE PITS I 1 Depth Size _ Number k t SUMPS El.. Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t 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 manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion taws of California." The pplicant m s call fo all r uir inspections. Co(nplete drawing on verse side Signed Title: Date: I FOR DEPARTMENT USE ONLY i Application Accepted by Date<,Z�_-ya Area F Pit or Grout Inspection by Data Final Inspection by Additional Comments: Q Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 F" Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE _h INFO AMOUNT DUE AMOUNT R ITTEO CK RECEIVED BY DATE PERMIT NO. CASH S F♦-EH 13-24(REV,i/N5) E { + ,� frrs'^'�'11 tc + Ek 14-2e 77 �.!h/