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S./ APPLICATION FOR PERMIT b/ 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. �/ rj�J,,(//J `l Job Addres )414yN ` IV, S0(L)I e S ^r^ JJ /CiiIItyy/ C9�)k4 Lot Size PMD&7O Owner's Name/414 AcidressN t ' • �"" e�IIID' / one 313 3-- Contracto Address License No3W9— Phone ti J3 f/}t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C PUMP INSTALLATION l`. SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER SEWER LINES — DISPOSAL FLD. PROP. LINE FOUNDATION _/D t AGRICULTURE WELLt,7W+ OTHER WELL PITS/SUMPS C; INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C, ❑ Industrial ❑ Open Bottom 7: Manteca Dia. of Well Excavation Dia. of Well Casing X Domestic/Private ❑ Gravel Pack 7 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 errs � e Ms l/ Well Destruction ❑ Well Diameter Sealing Material Itop 501 p. Sf SJ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION X DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence,y�Y— Commercial_ Other Number of living units: J-- Number of bedrooms_a 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/size 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." Contractors 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 compenm- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X C7'. l - Title: n Ili K C r Date: FOR DEP TMENT USE ONLY Application Accepted by Date Area d/ Pit or Grout Inspection by Date Final Inspection byGG�y7 Data Additional Comments: ❑ Stk 466-6781 Lodi 3�-3821 ❑ Manteca 8237104 ❑ Tracy 83x5-6385 Applicant- Return all pies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDWas INFO CASH RECEIVED ay DATE PERMIT N0. EH 1429 2 EH IflEV,r/e5� 1 (�`'t 03 LV a`10 —),Zo �l