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{� APPLICATION FOR PERMIT .; wf SAN JOAQUIN LOCAL HEALTH DISTRICT ! i A � 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.9862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 4 A V City s1661fhY*, Lot Size qOOtK. _ PM Owner's NameSfO� 2✓��Io 14Ss� Address /�� QUk/ �(� Phone �� 'y0 Contractorl Pr P P, n , C,2eP.AddressZZO hlv:?`�, "f—as( Sr< License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 19 M,,,"f.Ar;r1j6 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Wa DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El / Domestic/Private A Gravel Pack ❑ Tracy Type of Casing I' tIc Specifications (•1 Public fl Other Fl Delta Depth of Grout Seal Type of GroutL'Av` I I Irrigation 40—.r Approx. Dept f7, fad Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth �� Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) 0 Installation will serve: Residence_ Commercial__ Other Number of living units: Number of bedrooms 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 L1 No. & Length of lines Total length/size FILTER BED U Distance to nearest: Well _ Foundation Property Line r SEEPAGE PITS 1 I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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."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." Theapplic nt must call for I required inspections. Complete drawing on reverse side. Signed X Title: T VJ le--C A\ckd 01 CT-G32 �{ 2� Date: FDFJ\DEPARTMENT USE ONLY Application Accepted by vt- Jv�rvin Cvv...�._ Date '_�j�G Area Pit or Grout Inspection by \ Date Final Inspection by 4 Data 'b) Additional Comments: O Stk 466-6781 ❑ Lodi 369-362 ❑ 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 PERMIVNO. INFO a EH13-24(REV.t/H5) �!' EH 14-28 i .moi 1G