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t _ _ f E ' 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) f ` Application is he+eby 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 i Local Health District. �dQ Gfl, Job Address _ � 23?-030-0,?' City Lot Size __. PM Owner's Name MOSSV f/e— [�LSS�G TO Address PO Rod Y7P G 9,111h ro/4 W7'9 Phone Contractor e4tr M? Address 2-5L rf�G Sf� License No.tVR22,1317hone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR LlOTHER,I/� IMIAlpin, wellf, DISTANCE TO NEAREST: SEPTIC TANK &J SEWER LINES DISPOSAL FLDAY606 PROP. LINE ,,�{ ,,,,'' FOUNDATION! lyk AGRICULTURE WELL I ��. OTHER WELL PITS/SUMPSg�vze— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFI NS ri Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Gravel Pack R Tracy Type of Casing YL " %9 `Specifications i 1 Public Rypel.'i r fl Delta Depth of Grout Seal ZO Type of Grouf-" eit-dewta Ite,I Irrigation - r x. Depth t I Eastern Surface Seal Installed bRepair Work Done ❑ Pump I H.P. State Work Done_ Well Destruction ❑ Well Diameter_ Sealing Material (top 50.1 ranty20/ kIdIS Depth - �� Filler Material (Below 50') 20' TYPE OF SEPTIC WORK: NEW INSTALLATION I.; REPAIR/ADDITION . I DESTRUCTION ( I (No septic system permuted if public sewer is O available within 200 feet.) O Installation will serve: Residence —r ICommercial_ Other Number of livinq units: Number of bedrooms Character of soil to a depth of 3 feet: .I Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments , PKG. TREATMENT PLT.❑ I Method of Disposal Distance to nearest: Well Foundation Property Line 4i LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BED ❑ Distance to nearest: Well Foundation Property Line I _ _ SEEPAGE PITS I I Depth I Size _ Number SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 4 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. r 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of Califomia," Contractoc'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 The applicant�tallll required inspections. Complete drawing on reverse side. Signed X Title: /� �- Date: <• FOR DEPARTMENT USE ONLY 9 Application Accepted by _ Date r / Area Pit or Grout Inspection by Date Final Inspection by _ _. Date Additional Comments: P. Stk 466-6781 ❑ Lodi 369.3621' ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE [ INFO AMOUNT DUE I AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. EH13.24(REV.tin51 q .00!6--yo (Y)�' EH 14-26