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APPLICATION FOR PERMIT 2 SAN JOAQUIN LOCAL HEALTH DISTRICT so 1601 E. HAZELTON AVE., STOCKTON, CA 1� f 41d - Telephone (209) 466-6781 4-u Ke—v-c- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` �'FO'�'' ��-`� � "� (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. 649 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.. ` Job Address �" City -STZT j � Lot Size PM Owner's Name Address 1D�� C� ��/Y�/�tl� Phone 7` —, Contractor�� Address�1C;�6 I/&IL QX Z-License No. Phone TYPE OF WELL/PUMP: NEW WELL U WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR U OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LiNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS U Industrial C Open Bottom ❑ Manteca pia. of Wel Excavation Dia. of Weft Casing Domestic/Private L Gravel Pack U Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ 11 Irrigation _--Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done D Type of Pump H.P. State Work Done 14,R) AJa9// S dUP co 1 Well Destruction IV Well Diameter Sealing Material (top 50') A AE119S Depth Filler Material (Below 601 TYPE OF-SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal , Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines s• Notal length/size FILTER BED C '.;t'` Distance:to nearest: Well Foundation ` "Property Line SEEPAGE PITS O Depth _Size Number__ SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C 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 iaws,of-Califomia."-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." 4' The applicant m c a required ' tions. Complete drawing on r� ide. Signed Title: L_(L�IS Z. Date: Z� 04' FOR DEPARTMENT USE ONLY ]� Application Accepted by Date ^w' Area Pit or Grout Inspectio by " Date Final Inspection by Data AdditionalComments: Comments: ❑ Stk 466-6781 CLodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT'N0. +EH13-24(REV.i i e s) r EH 14-26 -7-2 WIS