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f I ' APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` (Complete in Triplicate) t 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. 8'dQ GId,7Y4 f st _ q �y Job Address d 23 1-030-©6 City Lot Size _ PM RO 7 1O Owner's Name MOSS g/e/ &ae, 4I Address 9+ 'r��'v ��V✓ Phone - eL�ry/f7 282.3`- Irl rr1`�a Sf' 1 2LL Ph�� Contractor. Address License No. �J TYPE OF WELL/PUMP: NEW WELL A WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER *M0,7/r60/J* ►1/�I�f� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 7rr PROP. LINE ,,��,,,,�" FOUNDATION!�/' AGRICULTURE WELL " OTHER WFLL� PITS/SUMPS 4�7_17 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFI NS / ❑ Industrial ❑ Open Bottom CP Manteca Dia. of Well Excavation _ Dia. of Well Casing ❑ Domestic/Private Gravel Pack Tracy Type of Casing , `!# T `Specifications [1 Public *yp er fl Delta Depth of Grout Seal ZD Typo of GrouF "��? �� fir(/ I I Irrigation - r x, Depth 1 Eastern Surface Seal Installed by PCom ^ Re air Work Done ❑ f Pump H.P. State Work tone Well Destruction ❑ Well Diameter Ftp Sealing Material (top 50'1 Tann 20� ` 6�1`_ dQ p//'� S�✓//' M r IBJ O!" h Welk Depth = _.,� Filler Material{Below 50') 11Gl(J1,i 2_CJ1 f7 V�\ TYPE OF SEPnC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is O available within 2{10 foal.] O Installation will serve: Residence r Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 'I Water table depth SEPTIC TANK ❑ Type/Mfg I T__---------------------- Capacity No. Compartments PKG. TREATMENT PLT.❑ I Method of Disposal Distance to'nearest: Well Foundation Property Line LEACHING UNE ❑ No. & Length of lines Total length/size FILTER BED D Distance to nearest: Well Foundation Property Line I SEEPAGE PITS I I Depth I Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 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, 1 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 lacus of The applicantst call for all required inspections. Complete drawing on reverse side. Signed X Title: ��- Data: FOR bEPARTMENT USE ONLY 9 I Application Accepted by Date r / Area �• r 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 i't 1 FEE AMOUNT DUE I AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT*NO. INFO �+� M p Q + EH 13-24[REV.t i n yl m ('��_1 � f 1 f lam. �• l J �� -- 033 EH 14-2e 1