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� ---+ 0 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT - 1601 E. HAZEL T ON 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. Job Address ARS .A—WIC DER= City Ugot Size r, PM t=_sEa Owner's Name ,,. s, AR" . Address l 1-T i*CC I Q Phone -43M 2 J Contractor tgn2TH k)AILt FLlU21 i(Add ess a= E. &-Y-t'Lr_NA&1 t_A_NCLicense No. 418fg Phone Vlw —OL TYPE OF WELL/PUMP: NEW WELL'y WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X fA0J t'Rf 2 WELL 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Oil Dia. of Well Casing A 4 ❑ Domestic/Private DKGravel Pack ❑ Tracy Type of Casing Qom- Specifications I'1 Public n Other n Delta Depth of Grout Seal Type of Grout I I Irrigation IISD Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump 1 H.P. State Work Done_ Well Destruction ❑ Well Diameter rf Sealing Material (top 501 20/t GEi.iF�NT F3FN'i�►S>F Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I I (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 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 Ll Distance to nearest: Well___. Foundation Property Line SEEPAGE PITS I I Depth _._-_ _.Size__._ Number. SUMPS L I Distance to nearest: Well__ Foundation Property Line DISPOSAL PONDS 11 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqui c 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." The applicant must callfor all re uire spections. Complete drawing on reverse side. Signed X _ �& -- Title: 6EOj .00't ST- Date: 42-1(0 -233 5 E Inc\ a ( FOR DEPARTMENT USE ONLY Application Accepted by Q � Date 2,19MArea Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Pam-it/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEI INFO AMOUNT �DUE ` AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. ♦ EH 13-26 EV.1�R5) S EH t428 VV