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og�o E)m - "I rf (0 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. �t / Job Address ��/7,�5Jip,r Q1 �CoT ,��.,��, Tre c City Lot Size — ) PM Owner's Name h e 1A.,vd, Address S�wrro O Phone Contra&r d y 90ff Address_i�i41 gox /1d yyS License No. 1"`f Phone 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 'a — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T Dia. of Well Casing ype of Casing El Public ❑ Other ❑ Delta Depth of Grout Seal Specifications ❑ IrrigationType of Grout _q pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. Well Destruction ❑ Well DiameterState Work Done Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Q REPAIR/ADDITION` DESTRUCTION ❑ (No septic system permitted if public sewer;is Installation will serve: Residence-1-0" Commercial Other available within 200 feet.) — Number of living units:__/ Number of bedrooms Character of soil to a depth ofd%feet: LoaM SEPTIC TANK Water table depth ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Capacity No. Compartments Method of Disposal Distance to nearest: WeLL Foundation Property Line LEACHING LINE ❑ No. & Length of lines ¢ FILTER BED1 ❑ Distance to nearest: Well Foundation Total length/size Property Line C/- F^ PITS ❑ Depth Size SU Number Ip' Distance to nearest: Welf 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 of California." The applicant must II for all required inspections. Complete drawing on reverse side. Signed Title: ��C1a/��. %�' i Date: �'�'��✓ n FOR DEPARTMENT USE ONLY Application Accepted byi/��1 G Date 7 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 AMOUNT DUE AMOUNT REMITTED INFO ASH RECEIVED BY9, DATE PERMIYNO. + EH 13-24(REV.t/as) EH 1428 / (r ,,,, j