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C e} } APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. ^ 1� �y 1 Job Address �.J ic. t°rl/� DLt, w City Loi Size PM l Jc�25 C. 6_1A_t f�7e✓ • Owner's Name _�l1(_�.�+'. s�..✓t��t��LAO�Address Q14,61-1 4211 6 Phone /57a &7A AOd Contractor OC ;,- Address 04 License No. Phon�g �w TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C] 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 r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private %Gravel Pack ❑ Tracy Type of Casing Specifications r [`1 Public ❑ Other Luk Delta Depth of Grout Seal SLzJ6 t0 Type of Grout r I I Irrigation 7D--..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter a Sealing Material Itop 501 jP6,g1>`3Ji Ayq Depth Z{)r Filler Material (Below 50') T F SIFPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION l I DESTRUCTION I I (No s=permittediflic seweravailaInstallation will se Residence— Commercial_____ OtherNumber of living units: umber of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ation Property Line LEACHING LINE ❑ No. & Length of lines �ngth/sizeFILTER BED ❑ Distance to sV Well Foundation SEEPAGE PITS Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DI AL 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 ail f)all �required �i pe io . ampl a drawing on reverse side. Signed X itle: �e /JfG✓GGy'- Date: _ 1� FOR DEPARTMENT USE ONLY Application Accepted by Date Area / - A Pit or Grout Inspection by �-_--___ Date Y Fi al Inspection by •C {�[�i�t�1 Da (6" r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl Manteca 823-7104 ❑ racy 935-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT•NO. INFO 1 4? • EH 13-24(REV.t i n 61 67- � 9�1 EH 14-29 : 7 } f /