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JAPPLICATION FOR PERMIT OAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED CA (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 f Local Health District.�a - Job Address 4A-FA 90 ' City � � Lot Size -�� PM ,t Owner's Name �/Ui4/Q L t S 1 e o Address 'L0 10 P/f/ o A-T Phone Yf 11 Contractor /leo Tly GRoy s Address A r3oX L'71 , Lc%0043111IZ1/XEicense N..,327-3 ?-C Phone l_3Y-Y7z�_*4 TYPE OF WELL/PUMP:' NEW WELL)i WELL REPLACEMENT, ❑ DESTRUCTION 4 PUMP INSTALLATION SYSTEM REPAIR`❑ 0TH ER L'' '' ' y ''` • P V, DISTANCE TO NEAREST:,SEPTIC TANK SEWER,LINES DISPOSAL FLD. PROP. EINE -FOUNDATION AGRICULTURE WELL OTHER WELL 1i9D PITS/SUMPS + INTENDED USE ` ,TYPE'C F WELL �: PROBLEM AREA CONSTRUCTION SPECIFICATIONS �0; ❑ Ind_ustrial 'rl. ❑_Open Bottom KManteca_,y E Dia.'of Well 6cavation Dia. of Well Casing LI Domestic/Private X Gravel Pack ❑ Tracy Type of Casing s rao Specifications [I Public ❑ Other 11 Delta l Qepth'of Grout Seal Y+,� Type of Grout{ CR ou t ❑ Irrigation /X-O Approx. Depth ❑ Eastern Surface Seal Installed by -rkAC T le Repair Work Done ❑ •Type of Pump Se H.P. moi. State Work Done Ola lYt�/iC/Ir� a We31 Destruction )?� epll Diameterae Sealing Material (top 50') ��u�7 th Filler Material lBelow 50') TYPE OF SEPTIC WO K: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is available within 200 feet.) F rt -�Installation,will-serve:•-Residence s -—Commercial-.---,-Other Number of living units: !Number of bedrooms , Character of soil to a depth of 3 feet: 1r Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ l + # }u 4� Method of Disposal # 'Distance to nearest:.-4 , Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 h i ��'CSEEPAGE'PITS j -`_�❑ Depth', Size Number SUMPS l ED Distance'to nearest:' ry Well Foundation Property Line DISPOSAL PONDS ❑ t y 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."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." ,, r. %. \ � f The applicant must call for all required inspections. Complete drawing on reverse side. Signed X .r a�-� Title: 06C*A_ I> _..- Date: /0-17- 16' FOR DEPARTMENT USE ONLY f Application Accepted by '�� Jl�f//2e— __ Date Area Pit or Grout Inspection by ate �Final Inspection by Date�u Additional Comments: I~e:11 � qF c Ho ❑ Stk 466-6781 ❑ Lodi 369-3621 anteca 823-7104 ❑ Tracy 835.6385 , Applicant- Return all copies to: Environmentalea h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH FIECEIVED BY DATE PERMIT NO. + EH 13-241REV.1/e5} / ,T -�,yl� / •r - 43 EH 1426 l