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J� APPLICATION FOR PERMIT �q SAN JOAQUIN LOCAL HEALTH DISTRICT 16.01 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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 Sari 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 W!/IL Z !�y t City W, S�T:A[,�ot Size PM Owner's Name 2V91A/S7,W Address S�M ir Phone(?/(, Dll 203 2_09) ertttar►4er+ .)W t,_7Aq��f`F . Address .2 l� a/fr et' i nse N .Pie�' �r hone Rr�O�� 9 TYPE OF WELL/PUMP: NEW WELL ❑ WILL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION'[] SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE S FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS o Al gL 6- W&fGa Ll51 4ewE% Industrial IDOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of et Casing ❑ Domestic/Private ❑ Gravel Pack _❑ Tracy Type of Casing Specifications f'l 'Public j Other ❑ Delta Depth of Grout Seal Type of Grout W J I Irrigation -Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done 17 Type of Pump H.P. State Work Done I Well Destruction ❑ Well Diameter �l y_.7t Sealing Material (top 501 - f Depth •��'. Filler-Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo 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 t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal ` Distance to nearest: Well Foundation Property Line �. l t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED' ❑ Distance to nearest: Wel oundation Property Line SEEPAGE PITS I I Depth A 44. Number ti SUMPS L-1 Distance to nearest' ell Foundation 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. 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 o ifornia." T The app cant m st call for all required ins tions. Complete drawing on re se side. Signed X Title: Date: R DEPARTMEN IDS ONLY f Applicatio Accepted by Dat /`` Area Pit or or Grout Inspection by Date Final'Inspection by Dates Additional Comments: C 1. aj ❑-Stk 466-6781 > ❑ Lodi 369-3621 ❑ Manteca 1123-7104 ❑ Tr 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Haze ton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE INFO - AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. - +.EH1 3-241REY.;/A5) ® ��. �3� EH 14-20 ,3 r,