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APPLICATION FOR PERMIT , w SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA N-0 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N� ,iWk z (Complete in Triplicate): cl X111 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. ` Job Address CitY Lot Size PM i 4 Owner's Name Address a K+ -ash Phone �cl Contractor . �ie ;Address �i3 d►Gt. ._ "' '/ t License No.4%P0 —0_Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION..❑ ..-_„ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTUREWELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTf1UCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ DomesticlPrivate ❑ Gravel Pack€ ❑ 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 YP p H-P. i State Work Done_ Well Destruction - ❑ Well Diameter . - Sealing Material ft p 50'j !!n= I Depth f .Filler Material(Below 50') t TYPE OF SEPTIC WORK: .NEW INSTALLATION IT REPAIR/ADDITION ❑ DESTRUCTION K fNo septic system permitted if public sewer is 'f available within 200 feet.) Installation will serve: Residence: Commercial Other . Number of living units: - .-.i.Number of bedrooms'""""" 7x Character of soil to a depth of 3 feet: M Water table depth .ptfiSEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT. EJ Method of Disposal Distance to nears it:.- Well Foundation Property Line LEACHING LINE' ❑ No. 6 Len th of line's • ` g ' r Total length/size �ILTER BED ❑ Distance to nearest: Well Foundation Property Line V SEEPAGE PITS ❑1 Depth Size ` Number 1 SUMPS _e , ❑ Distance to nearest: Well Foundation Property Line DISPOSALp 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. r. �`u _ 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 applica usi for all required ' pections. mplete drawing on reverse side. Signed Iel Title: ` � �� E ��g7 Date: _ FAR DEPARTMENT USE ONLY Application Accepted by Date Area jW Pit or Grout Inspection-byDate Fina( Inspection by Da Additional Comments: -3 ` ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 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 RECEIVED BY DATE PERMIT NO. INFO CASH + EH 53-24 IREV. i H 51 I i C 5 // p /f r EH 14.26 t ` itl (7-1G'l '