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FFP APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTS 1601 E. HAZELTON AVE., STOCKTON, CA REGel Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t�rf��Z `�� 01ga� (Complete in Triplicate) ��1l��A rtA�HEp,4�H Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work help plc f1 �1` �Ti+ ion is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules an eg > an Joaquin Local Health District. L Job Address 170J 44' 01 41 Ave _ City Lot Size AL PM Owner's Name 5-1441(&-4 C.s r Address SB ZO 9-CAe-171:41C Mall Pt j01e nS w6�?Vhone Y15-'/63 r 27! Pae,.t.{,'c- c4 �.` Contractor 6-r-o tr dw,kr- 1 c.�no(e dress fo80 AMC L4• 46+icOret CA icense No. y3 Phone` 61 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Sp - DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL /DO.t PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSn a ❑ Industrial 1711 Open Bottom ❑ Manteca Dia. of Well Excavation3" lt7�s;y>t� Or-W,'. of Well Casing Z LSD e Ii%�/rPLv to ❑ Gravel Pack ❑ Tracy Type of Casing pile , 6e4 y0 Specifications flf tlbt`-S ft�el� {Delta De ctFW n+yted Type of Grout Aad- if fytr.►1 P"] Public �p.S1� LI Otl�r Depth of Grout Seal? � ff _ IIIrrigation K2 Approx. Depth Il Eastern Surface Seal Installed by Grokr►c�W�11c� TPCNtAoI SItL. Repair Work Done ❑ Type of Pump Y1nV�e H.P. State Work Done >Kp W�f sp�5f4 caicSf (f5 I Well Destruction 0( Well Diameter 2Sealing Material (top 501 �rpuf rNe&/- C tl Ay,: Depth Filler Material (Below 501 S �•� oq TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUC ION l I (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 Character of soil to a depth of 3 feet: Water table depth Q SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: V Jell L�A/Foundation Property Line IZA LEACHING LINE ❑ No. & Length of tines Total length/size C FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number ' SUMPS ❑ Distance to nearest: Well _ 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 shalt 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,t_o:workman's compensa- tion laws of California." The applicant must call for allre ' d inspections. Complete drawing on reverse side. Pro e Geo�oy�s Date: 3 �3 Signed X ' Title: _. 1 6 of FOR DEPARTMENT USE ONLY J Application Accepted by Date r Pit or Grout Inspection by Date/ Final Inspection byan� 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 H RECEIVED BY ")ATEPERMIT'NO. - INFO +.EH13-24tPEV.I/n5l lZ EH N-28