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y a APPLICATION FOR PERMIT 1` 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) i 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. Job Address / F I I f I '9 kea�� ,EGCity Lot Size PM Owner's Name �rT P A W�ess_ S4A1d_,� Phone Contracto , Address lz /v. License No.P-74-47 Phone ,.. ---. .._..... �... �- - -� �- TYPE OF WELL/PUMP: NEW WELL 4. WELL REPLA EMENT'❑ r ,DESTRUCTION 17L \ _ _,,,„r, PUMP-INSTAL-LAT � ION- ,- "Jv--µ=SYSTEMA REPAIR--E- --"^— OTHER`❑ DISTANCE TO NEAREST: SEPTIC TANK 1 :2J2 SEWER LINES /.4Q2 4-1 DISPOSAL FLD/ee I'-! PROP. LIVE / Al FOUNDATION AGRICULTURE WELL OTHER WELL o2 51 PITS/SUMPS'. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC TI NS ❑ aLl ❑pen Bottom Manteca Dia. of Well Excavation Dia. of:Well-Casing Z �' lc/Private Gravel Pack Tracy Type of Casing n lJ ,..Specifications ❑ Public Ll Other ❑ Delta Depth of Grout Seal P. Type of Grout 177Irrigations � Approx. De h ❑ Eastern urface Seal.Installed,bye Repair"Oork'bone: }❑ fypefrotPump, H.P. „ /State Work Donee V Well Destruction� O WeII"Diameter ff Sealing Material (top 50')" Depth Filler Material (Below 501' .e to A 7F � TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available-within-200-fee0—t Installation will serve: Residence_ Commercial_ Other { 9 Number of living units: Number of bedrooms f 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 1 i 3 . LEACHING LINE ❑ No. & Length of lines l Total length/size rT., i FILTER BED Ll Distance to nearest: Well Foundation Property Line SEEPAGE PITS _❑ _.Depth�--- �'4r 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 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 n2o call for all requi ed nspectiops. Complete drawing on r rse side Signed X 11 Title: ` _� Date: f FOR DEPARTMENT USE ONLY �^ Application Accepted by Date a , Area Pit or Grout Inspection by Date Final Inspection by A. 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 9UO1 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE( �PyERRJMIVNO. + EH 13-24#REV. EH 1 -26 VVVV