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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 1$eZ,=N kAVC> Telephone (209) 466-67$1 95 rA7 C$ 19PAl-- g 8S-alp--z6 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED o7- (Complete T(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. z3` x 379 Job Address 4f�ILdAA' 1W r� City Lot Size I►7Z An PM Owner's Name rD/7r�Ln .51 Address _ �� / WW W 64. Phone V t JVI7X�P M Contractor Ame2y J Z5 5VS• Address,2f ZA 4P-License No. Phone TYPE OF WELL/PUMP: ti NEW WELL.jK WELL REPLACEMENT`❑' DESTRUCTION ❑ i.� PUMP INSTALLATION SYSTEM-REPAIR- —i - ----- OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.140' PROP—LINE —3—e9 - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 ► ►. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing. Aq- ,00 \AOGr64el Pack _17 Tracy Type of Casing STS€.L, Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout C ❑ Irrigation ; 24ZApprox. 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') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is t available within 200 feet.) Installatio ' serve: Residence's Commercial_ Other Number'of living urn Number of bedrooms s Character of soil to a depth o t: Water table depth SEPTIC TANK ❑ Type/Mfg ' _ Capacity n No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal` Distance to nearest: `' Well Foundation Property Line � 4 , LEACHING LINE ❑ No. & Length of lines ` Total length/size FILTER BED ❑ Distance to nearest: Well `- Foundation roperty Line \ V 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, 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.orsub-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 a for II req 'ed inspections. Complete drawing on rravje/rse Signed Title: '�®/y� L��GG/�- x Date: !� EPART ENT USE ONLY p Application Accepted by Date a Area Pit or Grout Inspection by Date J-[`.0/Final Inspection by /y Date Additional Comments: �✓ ❑ Stk 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY 1 DATE PERMIT-NO. �ERRMIT NO. t EH 18-241REV.1/B 5) _ y!�/ 1 • ^�0 EH 14-28 � C7 • O —C '-! �7—31