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r 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. r,' Job Address PJ©a )�G ��/�I�/ �� - City L 0A/t Lot Size PM Owner's Name KA v Address f /aO '5 C�6r0(tee, !` r Phone Contractor !N��fr�S�l Address � `I5 4V9iV�1f ��r �� License No. Phon��6 TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ Sa: t,mss PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X 1"0A 14-X7'( ,?-.•L DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE . TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS i1 jN`� ❑ Industrial EJ Open Bottom - 'Ll Manteca """ Dia. of Well Excavation Dia. of Well Casing 7 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 1P f Specifications ❑ Public El Other C] _Delta Depth of Grout Seal 3 feel Type of Grout L IFI �/�lyrQYl 1 ❑ Irrigation -- approx. Depth O Eastern Surface Sea! Installed by T tj�_/ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') �19,tJt Qf!`y Depth Filler Material (Below 501 TYPE OF SEPTIC'WORK: NEW INSTALLATION ❑ 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 R 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 I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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."Contractors 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 ust call for all rred�f se io . CoTitle:mplete drawing on reverse side. Signed X 3 D RT E T SE ONLY p Application Accepted b r p Date ` z- Area_ �/ Pit or Grout Inspec on by Date �� [ Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lo ' 369-3621 ❑ Ma ca 823-7104 ❑ racy 835-6385 Applicant - Return all copies to: Environmental He Ith Perm. /Seni es 1 E. Ha_zelton Ave., P.O. B x 2009, Stk., CA 95201 M w K IX � FEE AMOUNT DUE AMOUNT REMITTED R EIVED 8Y DATE PERMIT NO. INFO �7CASH ! ty�� (X� a EH 13-241REV.i/851 Jt-ll Uv L.. s 3 417 v -7—//9-3 EH 14-28 -5; ,.1/41.