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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) 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. r� Job Address Pdal � 0( KO.�iAI A ,��,,ylCityM'4J Lot Size PM Owner's Name 40k,4611!41- ��(�.�.�fiDA� Address r��i��_cA/``aay6409!d� A-4 Phone -467S e. �,PIIWILE Contractor-1viF!• 1�..1?IAfk1JW40&ss..3`iGCK l�iQ 9. 5 License No. 416#1��2F`ho `L0-13q! TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER`WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I.D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 410 PVe— ?1 P=� Specifications \� ❑ Public Iffi Other CdA$JD) ❑ Delta Depth of Grout Seal —45 Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by'-T.11, NFE1.D>'>A b M✓�L Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destrucion ID Well Diameter Sealing Material Itop 50') -W OL kem i Mi's/ ue th Filler Material (Below 501 TYPE OF SEPTICWORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 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 CapacityNo. 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 p y— (SUMPS ❑ Distance to nearest: Well Foundation Property Line of DISPOSAL PONDS ❑ i 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. 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 -10 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." .�7 The applicant st call for II re nir ins tions. Complete drawing on reverse side. ,,/�� �l igned X Title: el(�l�Lj Date: O FOR DEPARTMENT USE ONLY pplication Accepted _ Date Area Y5 it or Grout In n C-C.f-rDate ;5--/3_4 Final Inspection by Date \ &,o 0 Additional Comments: b[7!. NSs Rfl'(1 (� ❑ Stk 468-6781 ❑ Loci 369-3 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: E ronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ,VJ rad , �� �6od�rR INFO AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERMI7'NO. SEH 14281REV.r/x51 .SS �.r� s s li 5'-(V-P-7 O