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APPLICATION FOR PERMIT plopS tV AN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ., PERMIT EXPIRES 1YEAR ;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 i Local Health District. j j Job Address ' I D 2 3 � ti` 62 S Ro,4 City &e11 Lot Size 40 PM Owner's Name S�QAA�I s Address Phone Z �360 Contractor Mfic h 11 1 4MR Address Reed 9041d Mall license No. 6-95- Phone �9 03q TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION #L, SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIG,TANK � 11 SEWER LINES 1'�I�' DISPOSAL FLD. PROP. LINE 114D� FOUNDATION Zfl° AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF"WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS sl ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 11 Dia. of Well Casing &-Domestic/Private &Gravel Pack E1 Tracy Type of Casing :5 'e_ Specifications FI Public C1 Other --__ _._ _D Delta Depth of Grout Seal Type of Grout (Z> I ) Irrigation ..Approx. Depth ( I Eastern Surface Seal Instaljed by Repair Work Done ❑ Type of Pump �QLhM H.P. /!/2 State Work Done_ Well Destruction ❑ (Well Diameter - �' Sealing Material (top 50') f Depth ;` Filler Material (Below 50') V\ TYPE OF SEPTIC WORK: NEW INSTALLATION I;1 REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is ) it available within 200 feet.) Installation will serve: 'Residence_ Commercial_ Other Number of living units: Number of bedrooms "Qi � Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK I❑ Type/Mfg f Capacity i No. Compartments PKG. TREATMENT PLT.'❑ Method of Disposal Distance to nearest: Well i Foundation: ' Property Line LEACHING LINE,, �❑ No. & Length of lines A,,Total length/size FILTER BED p. .❑ Distance to.nearest: Well-� Foundation y. Property Line SEEPAGE PITS ti-,1 it I Depth Size 3 Number C\ SUMPS ❑ Distance"to nearest: Well Foundation I Property Line DISPOSAL PONDS ❑ } 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. i a 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 applicantJ<vst call for all required ins erns. Complete drving on reverse side. { Signed X - _ -% ? 'Title: t .�$` Date: +Z1"'1r/� 3 F0Q DEPARTMENT USE ONLY Application Accepted by _ DateArea I QJ Pit or Grout Inspection by Date S �� Final Inspectionby Date Additional Comments: ❑ Stk 466-6781 O"'L'odi"`369-36219^'""`- "Mi niece'823-7104 O`Tf c`y`=835:6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.,Hazelton Ave.,`P.O. Box 2009, Stk., CA 95201 3 FEE CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITT''N�OJ. +.EH 13-24IREV.)in9) Way / ©® ��s(� EH 14-26 ��$� ( ! v 7 ' i e