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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 County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.(� �j j� _ -1' ' /�- q;ron,.� 4.5O f Job Address 1 I ! d T7AYlao IRA cit' f( cl_ of Sized) Ae-YC- PM Owner's Name �ey i�Ia fmdeV<C.C� Address 1976 Looibare Sah F)-Gm Phone 3 -O Contractori4 f'9 A 4-L& Address 'n,BoY-J gdJr JIMCK ION L ense No.5�2/6�� Phone ! Tq'.S 6y TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Y' DESTRUCTION ` PUMP INSTALLATION 5?-/ SYSTEM REPAIR ❑ OTHER ❑ �� DISTANCE TO NEAREST: SEPTIC TANK ISO SEWER LINES 1.50 DISPOSAL FLD.�� PROP. LINE 00 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 10" Dia. of Well Casing -p VDomestic/Private VGravel Pack ❑ Tracy Type of Casing 'r Y C_ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 160, ,1. T pe of Grout Ce441e AT I I Irrigation —Approx. De�t`4h�� I I Eastern Surface Seal Installed by C 4 1 WQ/fY �Y+L It 1 R� Repair Work Done ❑ Type of Pump 113 H.P. e1 State Work Done MfW we Well Destruction Ig Well Diameter S.. Sealing Material (top 501 Depth AOr Filler Material (Below 501 V� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is (" available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ; 'w _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. & Length of lines Total length/size r FILTER RED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ 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 District. Home owner or licensed agent's signature certifies the following: "1 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 taws of California."Contractors hiring or sub-contracting signat ur 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 laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: C(X71 /L(;liC/� Date: AT 61 r FOR DEPARTMENT USE ONLY Application Accept y _ _ Date Pit or Grout Inspection by Date,_ Final Inspection by Datel__416A Additional Comments: U ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r ,� INFO !�y�AMOUNT DUE AMOU/N�Ttr'/R`�EMITTED CASH ,,�,,Rttty��E,,C/,/EIIVr ED BY U DATE PE�yRMIT NO. X r1 we,�1 . EH 13-24(REV 1 IV 14 fy�\ I �� 11 EH 1424 FI'" Q'G_11 a n ,n ..ab