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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICY 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. IBM for well/pump and the Rules and Regulations of the San Joaquin Local Health District. n p •C/e7-' 0-3= /e&�O.QQ Job Address yfo0 � q City s" �/ Lot Size AGP-!:S PM Owner's Name MLEy 41 /Aw Address 43 SS AJ- 0"Aim S7y2?24M44 Phone Comraqtor's Name j!5&t" G • Ldms+D License No. 44117Y74- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT b DESTRUCTION ❑ PUMP INSTALLATION ❑. SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL .OTHER WELL PITS/SUMPS 7\•\ INTENDED USE TYPE-OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION 4 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Q ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DEPTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Z Commercial_ Other - Number of living units: Number of bedrooms Character of soil to a dept f 3 feet: 1nL Water table depth P n SEPTIC TANK Type/Mfg Capacity` AI212 No. Compartments PKG. TREATMENT PLT. ❑ ' Method of Disposal Distance to nearest: Well d<t� Foundation A& Property Line LEACHING LINE - No. & Length of lines — �``d�A i Total length/size 7 FILTER BED ❑ Distance to nearest: Foundation �'�� Property Line /04 SEEPAGE PITSDepth .�-al�i SizeJP nni Number e� .w� SUMPS El Distance to nearest: Well JQf6� Foundation Z Property Line 10Yl 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, 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 laws of California." _ The applicant must call for all required inspections. C plate drawing on rreev.v.9ise side. Signed x�' /� ..-�.�� `� Title: ( Date: -- - ,FOR DEPARTMENT USE ONLY Application Accepted by O Yr•-- -- �+.-..\, Date �^��-' Area d '` r 1nt it or Grout Inspection by ktT_ Date -1-U^ ^Final Inspection by I-XV 9. -._s- Additional Comments: — ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104. ❑ Tracy 83663% Applicant- Return all copies to: Environmental Health Permh/Servioes 1801 E.HAehon Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK' RECEIVED BY DATE PERMIT'NO. INFO CAS4 + EH 13-24 IREV.10103 EH W26