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APPLICATION FOR PERMIT -V R SAN JOAQUIN LOCAL HEALTH DISTRICT 2.7`"� 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. i' 1D23 S 1 '! � Job Address Moles R®4 City vl Lot Size40 aCfe-5 PM Owner's Name 1-64c, SSgQmCkr,S Address Phone 67L -136D ContractorAl �• 1 dl Pum Address � Reed I�06J ,(y WAICLicense No. 6-8� Phone�� 'D�� r TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION b SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIG,TANK 1501 SEWER LINES f��'r DISPOSAL FLD. PROP. LINE y�1 FOUNDATION Z2t AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �- Il ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f 11 Dia. of Well Casing _ __ kDomestic/Private 6Gravel Pack ❑.Tracy Type of Casing- t �7 Pe. Specifications FI Public F1 Other --- ,►,Pelta Depth of Grout 1"S ®b ( Type of Grout ) I I Irrigation .-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ ►Type of Pump t/bo H.P. 02 State Work Done_ l Well Destruction ❑ Well Diameter Sealing Material (top 501 ' Depth '' •"3 -Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION 1.1 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 y No. Compartments PKG. TREATMENT PLT..;❑ Method of Disposal Distance to nearest: Well'° `- Foundationt I � Property Line LEACHING LINE ,❑ No. & Length of lines rNotal length/size FILTER BED r; :❑ Distance to.nearest: Well Foundation Property Line SEEPAGE PITS i I I Depth • Size # , Number SUMPS ❑ _Distance to nearest: Well Foundation 1 Property Line DISPOSAL PONDS .❑ l 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 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, 1 shall employ persons subject to workman'scompensa- tion laws of California." I The applicantm�for all required ins c'ons. Complete dr Wing on.reverse side. TSi Signed X 'Title: Date: FOffl DEPARTMENT USE ONLY Application Accepted by =Date Area G ^ ' Inspection b S: Date �J in I in P Y l spection tby Date Pit or Grout Ins a titi Additional Comments:. ❑ Stk 466-6781 O-Udcli"369=3621 Manteca`823-7104-` O'Ttacy`m'835=6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,-P.O. Box 2009, Stk., CA 95201 i INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMI{T�NO. +.EH13-24(REV.1in5) i EH 14-26 aQ� ( r •oa