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v APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELiON 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 Ryles and Regulations of the San Joaquin Local Health District. ' ' qp 1� Job Address J I 1 S SIX MA, SMgM AWM: if ; 'T�- I?kY�pLot Size PM ne Owr's Nsme,7-s MSAA� - Address S:�_�KMK) C, Phona2—M JA �actorA J6s a-hA.tJ 1� /L��., Contractor� ljA, 1�G Address�fJ,31(yS;lf$nl�(R%45J"License No. S��hon TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT )K- DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excalation ff Dia. of Well Casing 12 lb ❑ Domestic/Private W Gravel Pack ❑ Tracy type of Cesi Specifications tA ;K Public Cl,,�O/th�er ❑ Delta Depth of Grou Seal t Type of Grout ❑ Irrigation 14�9pprox. Depth ❑ Eastern �S^urface Seal Installed by Repair Work Done ❑ Type of Pump�H.P. Tom° State Work Done 7A:kSz[SX-AU69TL— Well Destruction ❑ Well Diameter � Sealing Materiel (top 50'1 Cl.]I1T.CAC'ra� Depth Filler Material(Below 60') 6101 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted 8 public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ' Number of Irving 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/sI FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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, 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 s. Complete drawing onn,reverse side. Signed X Title: .t !1_ ��/ '-�� Date: FOR DEPARTMENT USE ONLY Application Accepted by H,NWL- Date — -ZS' Area _ Pit or Grout nspection by /L�ii, . gs,— ate k a'NFinal Inspection by Date 7�7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mentees 823-7100 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 18111 E. Hazehon Ave., P.O. Box 2009, Stk., CA 9115201 INFO AMO/U[�N�T DUE AMOUNT flEMITTED CK CASH RECEIVED BY DATE PERMIT NO. • EEH H ls.za1REV.r/ail .GJ 1