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nT 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. ,e� Job Address �r� /�Z._cla�A.^ i4�- City Lot Size PM � 24106 Owner's Name Pmdu�T�._.. L - Address Phone �� 1'3CJ 41 /I T9 o 3 Contractor Y G4Y� Address License No, �Phon 3- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X SCI2l bIWA*Z�,O n DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 7 D FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 8 r� Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i'1 Public ❑ Other ❑ Delta Depth of Grout Seal ko Type of Grout r61 1 1 Irrigation �..Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 50'1 1 So tir SGL In Depth Filler Material (Below 50') TY F SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION [ I DESTRUCTION I I (No septic system permitted if public sewer s� available within 200 feet.) Installation will se • Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: er table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest; Well ation Property Line . LEACHING LINE D No. & �oflines ength/size FILTER BED ❑ Distancell Foundation Pro Line SEEPAGE PITS Depth Size Number SUMPS ❑ 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 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, 1 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 Califor ' The applicant m t c Ii for all requir ins tion omplete drawing on reverse side. 011 The CSC&4dZCI) Signed Title:�� C/��rllll7/✓� Date: E R USE ONLY Application Accepted by Date �" Area Pit or Grout Inspec' Date Final Inspection by Date 7 �� Additional Co Is: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63$5 Applicant - Returri all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDASH RECEIVED BY DATE PERMIT'NO. INFO s /� t EH 13-24 1REV.I/K sf r OE EH 1429 ✓ ✓✓JJJ 1 3 5%drJ dJ f