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%fte APPLICATION FOR PERMIT .,,e 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. "6we 7✓ " Job Address /1239-o3O-016" City/`+�"� Lot Size PM Owner's Name IYIoSS(/4�G ASSOG t0 Address PO "0 y717 G9�h roto 73:ye pPhone LL Contractor SP'ne0'r111)7 Address Mrrrie st License NoE T 21G Phone� JJ TYPE OF WELL/PUMP: NEW WELL A WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OOTH�ERXM0,71"61"/1' Wel/f' DISTANCE TO NEAREST: SEPTIC TANK 1J' SEWER LINES � DISPOSAL FLD.[1f�L�_ PROP. LINE FOUNDATION AGRICULTURE WELL && OTHER WELL *& u'_PITS/SUMPS z/�G INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFI NS E) Industrial ElOpen Bottom Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private le Gravel Pack Tracy Type of Casing YG 'P 0 Specifications//''�� I'1 Public e er ❑ Delta Depth of Grout Seal 0 Type of GrouF"mI I Irrigation r x. Depth 1 I Eastern Surface Seal Installed b, ev�Repair Work Done ❑ f PumpH.P. State Wor ,kDone_ Well Destruction ❑ Well Diameter I Sealing Material (top 50') TOP l� - �� A�r6 S�✓��' wdh Depth -K/ � Filler Material (Below 50'1 4/01.z .ZOy J TYPE OF SE C WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 ) DESTRUCTION I I (No septic system permitted if public sewer is O available within 200 tee[.) (� 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 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 11 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I 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 D13trict. 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicantst call for all required inspections. Complete drawing on reverrs�set1 side. Signed Title: --- Date: 21-1y- 91 FOR DEPARTMENT USE ONLY / Application Accepted by r � Date Area �• Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ 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 FEE gMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO l/�1 �+� CASH M(y�'� �J�/ t�-�/l /y'� Q . EH I3-24 IREv.rix 5) y coW �q •0V �U 1 / I/�. L/" I ! ' 11 1'— D�� EH 14M 1 R 6 v1 1,.4 `{i