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a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA LP Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - 4a ., � .. (Complete in Tripficate) t j - 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 al Health District cewith San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Job Address"3 � 1'v 9,1A< .T Cjle-6V4F Ab, h City L'ot S,ize Sy PM /� C& ;:r'a't r� ;. ,v,,.. Owner's Name J'k A I_V11V C!' A e.� :Address-9165o ,uk1AZMJ_� G a k VE �b Phone�L` ��// r Contractoref'T fts - Address?" COY I7 k tA")00D*klb1& 773 1-S 33"t-V�-s License No. Phone i TYPE OF WELL/PUMP; NEW WELL WELL REPLACEMENT ❑ DESTRUCTION I PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES lam. DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL t PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_( Z Dia. of Well Casing Domestic/Private ] Gravel Pack ❑ Tracy Type of Casingk El Public p Other � — Specifications ❑ Delta Depth of Grout Seal S c'a Type of Grout ❑ Irrigation L 41,aApprox. Depth ❑ Eastern Surface Seal Installed by T-0-R ft Repair Work bone ❑l Type.of Pump H.P. State Work Done- Well Destruction ❑ ` :Well Diameter Sealing Material {top 50'IJk " ' x Depth Filler Material (Below 50') 1 f TYPE OF SEPTIC WORK: NEW INSTALLATION LlREPAIR/ADDITION LlDESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) i 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 d SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 1`7 � - ! Method of Disposal Distance to nearest:. Well Foundation Property Line s # i LEACHING LINE'-- ❑ . No. & Length of lines } Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number S SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ; 3 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,foilowing: "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." Y The applicant must call for all r quired inspections. Complete drawing on reverse side. Signed Title: Q'tl?'w- / p Date: ` FOR'DEPARTMENT USE ONLY Application Accepted by p Date Area L� Pit orro Inspection by D to Final Inspection by Date , Additional Comments: c7 C E] Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 � Of ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box'-2009, Stk., CA 95201 t FEE � AMOU INFO NT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT"NO. CASH EH i3-24{REV,1/a 5) EH 14-28 .1/y 9-797+ r