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APPLICATION FOR PERMIT SEE/ 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.509 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District./I!' � - 1 Job Address 14444 Pews ,I KI Av City SJ"Az>v,\ -- Lot Size ISO' X ISO' PM Co1200 rGw r'fk 34. 9✓;4C /DSO OwnerXW Owners Name E 7k1 W . U.S.A. Address AOV Sfdv1f I X 'fi'�OOZ Phone 13 b56' 94547 Contractor—96 9h cen'tt Address �1 G G C'E. Cf rA License No. F(r 07 6' Phone 41S•193." TYPE OF WELL/PUMP: NEW WELL n WELL REPLACEMENT n DESTRUCTION n PUMP INSTALLATION n SYSTEM REPAIR n OTHER g sDII Ua�oT" DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL S'-len' PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it Industrial LI Open Bottom ❑ Manteca /D�/'a. of Well Excavation Dia. of Well Casing I i Domestic/Private ll Gravel Pack L I Tracy ,/Fype of Casing Specifications i'; Public I}i Other I 1 Delta Depth of Grout Seal _ Type of Grout I I Inylabon 1e Approx. Depdr I Ie udaee Seal Installed by _ Repair Work Done I.I Type of Pump P. State Work Done _Well Destruction 1:1 Well Diameter Sealing Material (top 50'1 8eA'EDyI�� @)�E"f'S DY yy�'} SIafY�� Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALL ION I-] REPAIR/ADDITION I I DESTRUCTION I I Wo septic system permitted it 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 El Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. n Method of Disposal _ Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. 8 Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number _ SUMPS 1 I Distance to nearest Well Foundation Property Line DISPOSAL PONDS Il I hereby certify that 1 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." Contractors hiring or subcontracting 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 applican rust aT for at requir n actions. Complete drawing on reverse side. / ,,,( Signed Title:�e'1 r/IYLr1Vl✓pti DNM1�h� (r O Tf Date: Zn App FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date _ - ------ Final Inspection by Date Additional Comments: n Stk 466-6781 n Lodi 369-3621 ❑ Manteca 8237100 n 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 CK RECEIVED BV INFO CASH GATE PERMITNO. . EH t124 IREV.11 x sr EH 14M