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APPLICATION FOR PERMIT SAN JOAOUIN LOCAL'HEALTH DISTRICT 1801 E.,HAZELTON AVE., STOCKTON, CA Telephone (209) 468.8781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED ' f k nF (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.509 for sewage or No.1962 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. °..� Sr �. Job Address V(�S�r�i�crs nn rsRrQQ acln e,. r �.-. �in;r J, �N'R'*Lot 5iie "��• C .PM E .. (� LlJ1 . II'-:+UC" '7 ✓.. E 9 t y. •.7 y�.�.iv.-.�7�rTia :W "..e _ ///7 /,/1 Owners Name v-cv f� F(�-(�^WC•�' -. Addre�s7 c�aK� / ! .L^CL' Z/S 1 Gx--'..Phone -- u// . S. . Contractorcl A lu ��'CJ�JML Address 15 03 AJA'�y' bwf— License No. 35�Zs9 Phone qr S 41 Z TYPE OF WELL/PUMP: - NEW WELL �❑ WELL REPLACEMENT LI DESTRUCTION ❑ tel PUMP INSTALLATION /. SYSTEM REPAIR,[] OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL - PRS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i$IndUstdal ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Die. of Well Casing X Domemic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ^ ❑ Irrigation --Approx. Depth ❑ Eastern t Surface Seal Installed by �l Repair Work Done ❑ Type of Pump V.M H.P. I /Z $IJ Se _ State Work Done 1(4—aM �A Well Destruction ❑ Well Diameter ._ Sealing Material (top 5(y) LJ Depth Filler Materiel(Below SO') TYPE OF,SEPTIC WORK:.,,NEW INSTALLATOON-❑ . REPAIR/ADDITION ❑ .DESTRUCTION ❑ (Nonseptic system permitted if public sewer-is—�. ...:; available within 200 feet.) Installation will Serve: Residence_ Commercial_ Other Number of living units:_ 'Number of bedrooms r " Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 0 Method of Disposal ' Distance to nearest: Well Foundation Property Line I LEACHING LINE - ❑ No:6 Length of lines Total length/size _ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth -Size Number ' SUMPS ❑ Distance to nearest: Well Foundation Property Lim . DISPOSAL PONDS ❑ j ' 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, 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 folkrwwing:"I certify that in the erformance of the-work-for which this permit is Issued, I shall-employ persons.subject to workman's.c impensa- tion laws of California." The applicfiffr7ralist Pil for all -i i actions. Complete drawing on a side. Sgned ! Tile: - -�. Date: - -'{ - - - FOR DEPARTMENT USE ONLY Application Accepted by ` Date Area Pit or Grout Inspection by Date Final Inspection by- Dste Wdditional Comments: tk 486-6791 ❑ Lodi 3893621 - ❑ Manteca R23-7104 ❑ Tracy 83&6385 A Applicant- Return all copies to: Em4ronmemal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box Am, Stk., CA 96201 FEE INFO AMOUNT DUE y_ '._ AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. EN K}a ` � 3'S'o o _ I Zs1 �. Yi*9'c� 8b-3(o .-