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APPLICATION FOR PERMIT SAN JOAQUIN'LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplicate} — Application is he 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 F Local Health District. �1 Job Address � �/� lV i 6e L-O -- City W jlG 7 Lot Size PM Owners Name 1heAs&o ine-w4E F AfAress .1-799--0 V16 IVf"1-0_ Phone 9336— 0 Contractors11k -Address ZS E?.-M_�JfZ Lf 5r License No. q6�Z Phone744-8-1541F.- TYPE "` 3 i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ iPUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr Industrial /r4A/��O ❑ Open Bottom ❑ Manteca Dia. of Well Excavation " Dia, of Weil Casing If ❑ Domestic/Priv El Gravel Pack '� Tracy Type of Casing � �C- Specifications. ❑ Public 9 Other -%+*raj 80&4-❑ Delta Depth of Grout Sea] Z Type of Grout"9AL SAI- M ❑ Irrigation !]!)Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter 46 Sealing Material{top 501 Depth��f __ Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is (� available within 200 feet.) \P Installation will serve: Residence_ Commercial_ Other' Number of living units: Number of bedrooms \ y Character of soil to a depth of 3 feet: Water table depth v 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 ❑ 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 compensa- tion laws of California." ' The applicant must call for all required inspections. Complete drawing on reverse side. yP11J l Signed )C --- . Title: Date: FO DEPARTMENT USE ONLY �1 Application Accepted by e T r � r Area 17 Ph or Grout Inspection by e o�/ xDai Final Inspection ! ate i Additional Comments: ` ❑ Stk 466-6781 ❑ Lodi 369-3621 VManteca 823 04 ❑ Tracy 936-6385 { Applicant- Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT`�"NO. INFO +EH 13-24{R EH 1426 C EV.1/e 5) R- 3 _ xi LA /