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/P:i A.w� APPLICATION FOR PERMIT 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. �+ 'p Job Address F-z-l� �/T��'��'BL� ��z7 "F City Lot Size PM Owner's Name tA6- A&X Address �TT,�r,,y a Phone — n, Contractor ice( &W& AeD lzyz�� Address�A� /3212 C� License No. Phone — TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONS PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL Fi 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 Ezca ation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Detta 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 50'1 ��'7Lr J Depth Yo.1Q// Filler Material (Below 509 5?010 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION O (No septic system permitted if public sewer is J available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms (/1 Character of sell to a depth of 3 feet: Water table depth I0 SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal C�C Distance to nearest: Well Foundation Property Line v LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Cl 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 subcontracting 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 11 a ue in o Complete drawing on reverse side. Signed X jQ/'1? �t*1 Title: sr�"',�%�11�6_Y.�l SCS Data: FOR D/E9,,ARTMENT USE ONLY n (+ Apptic�rion Accepted by v y�H Date `^�' <p" 6 Area Pit or, =rout'.upection by [Date (�Fiinnal Inspection by S ,(E.-) Date Additional Comments: �absu.-ir! " O t t .w,<-'—"• � '�'n ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mantes 823-7104 ❑ Tracy 83S Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT flEMITTED K# RECEIVED BY DATE PERMIT NO. INFO CASH I . EH 13101REV.iia �SAp EH ILS