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� r 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. ,�71 Job Address J� N. ; /ny44#14- AV,� CIS' Lot Size PM Owner's Namedam/u �az Address 40M. � QA.� CA- TYPEContractor AAO Address �Qyyj^�y��„ CA-• TYPE OF WELL/PUMP: -u`-/--L.��rr License No. Z1W 3/O Phone Sgt^96 NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ vm PUMP INSTALLATION SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ �� SEWER LINES DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE WELL INTENDED USE OTHER WELL PITS/SUMPS 14t TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA I NS I elnel /UCI`�fTdYt- ❑ Open Bottom CONSTRUCTION Dia. of Well IONS ion t/( r t ❑ Domestic/Private 12 Gravel Pack ❑ Tracy eve, Dia. of Well Casing ❑ Public Type of Casing 4 Other ❑ Delta Depth of Grout Seal SQL D4WIA14 Specifications ❑ Irrigation !�-E46/Approx. Depth 13 Eastern Type of Grout/ A'l Repair Work Done ❑ 7 p VSurfa a Seal Installed. 33KYI� QyL, Type of Pum 'S ld/b/Yi H.P J��z �� Well Destruction ❑ Well Diameter ` ^ Sealing Material (top 501) State Work Done v , Depth Filler Material (Below 50') \ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system pe _ Number of living units: rmitted if public sewer is Installation will serve: Residence available within 200 feet. ^ Commercial_ Other l Jj\a _ Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity No. Compartments Distance to nearest: . WellMethod of Disposal Foundation Property Line LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Well Total length/size Foundation Property Line SEEPAGE PITS ❑ Depth Size SUMPS ❑ Distance to nearest: Well Number DISPOSAL PONDS ❑ Foundation Property Line 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 a become subject to workman's compensation laws of California." Contractoes hiring or sub-contracting signature certifies the o : "I ce ' that' t e performance of the work for which this permit is issued,I shall employ tion laws f Californ il,� p y persons subject to workman's com 6 pensa- The applic t I o all r inspect ns. Complete drawing on reverse side. Signed Title: HYBr"S TDate: Z3 SBV B,.' FOR DEPARTMENT USE ONLY Application Accepted by r 2�'-V �+ Pit or Grout Inspection by Date Area D 5 Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 389-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant eturn all copies to: Environmental ealth Permit/Sem' 1601 E. He eltonAve., ox 2009 Stk., CA 9 3 00 � -,e. A �e EF K AMOUNT DUE AMOUNT REMITTED C H RECEIVED BY DATE PERMIYNO. +EH 137A(REV.1/eW EH 1418 GG S. ri 9/13 ob_121