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w APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. Job Address 'Y3�u tdl�r�.sa,....- ��T_?_FFA City .5Y6cvtroaA Lot Size PM Owner's Name kAYD -.4h, 4e624-4-1 Address oeo ZQK If,, Phone 60J 368—.27$1 n•. E3tplauacwr-, QeQS C �uy,�H� ,°" �a� y��asa Owl) 1qA-154 TYPE OF_WELL/PUMP: NEW WELL (� _ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /'DISPOSAL FLD. PROP. LINE 1_ {?� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Rif Dia. of Well Casing 2 X Domestic/Private - (A Gravel Pack ❑ Tracy Type of Casing_ -Piz( SCA q0 Specifications FI Public 4A07&)1',g1 n Other ❑ Delta Depth of Grout Seal33�_ Type of Grout .{lv�ef CPm.e.�fi I I Irrigation w'�� .Approx. Depth I I Eastern Surface Seal Installed by JI'rt"ie- Pic _ Repair Work Done ❑ Type of Pump H.P. State Work Done'_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') T PE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION f I Wo septic system permitted if public sewer is r available within 200 feet.) Installation erve: 'Residence_ Commercial--Other Number of living unit Number of bedrooms Character of soil to a depth of r table depth SEPTIC TANK' 0 Type Mfg Capacity 7 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ndation Property Line LEACHING LINE ❑ No. & Length of I' ength/size FILTER BED ❑ Distanc nearest: Well Foundation Prop", Line SEEPAG�PITSI 1 Depth Size Number SUMPSL] Distance to nearest: Well Foundation Property Line D SAL 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 taws, 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 of California." The applicant must call for all raqu' d inspections. Complete drawing on reverse side. Signe A. +�-�— it e: cc Date: --- -7 'Tec.L,.rMle FOR DEPARTMENT USE ONLtY �Y . ! Llt,. dR i Application Accepted by Date ' Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 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 95201 ' FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. r EH13-24 IREV.v/x 57 EH 1128