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APPLICATION FOR PERMIT w SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE TON AVE., STOCKTON, CA Telephone (209) 466-6781 /tea y0 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Gw / (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. s appli i 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. +t. .4 e"S�.eo oaf ��' U /Job Address _�{_?ZYp f. C`�oae 77er City CaL Lot Size 40 �PM Owner's Name A6&44M dN _ Address AwJ! / !gg I AM Phone # Contractor Z&;%;dPSAC aA4 099 Address MU N &19�ts� r License No. 44S Phone TYPE OF WELL/PUMP: NEW WELLVr WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION L SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 90 SEWER LINES 4 DISPOSAL FLD- PROP. LINE 4� FOUNDATION AGRICULTURE WELL OTHER WELL_y__� PITS/SUMPS /t5:F" N INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 09 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F *Domestic/Private fXGravel Pack ❑ Tracy Type of Casing &e_ Specifications 140 � ❑ Public ❑ Other ❑ Delta Depth of Grout Seal S'19` Type of Grout r ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by : Repair Work Done 71 Type of Pump S d _ H.P. f State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') .`_Depth FillerMaterial IBelow 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 1 Number of living units: Number of bedrooms [ Character of soil to a depth of 3 feet: Water table depth Y+ SEPTIC TANK ❑ Type/Mfg j Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal e Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size f FILTER BED ❑ Distance to nearest:, Well Foundation Property Line SEEPAGE PITS ❑ Depth W Size 1 Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 7 DISPOSAL PONDS ❑ t J 'n 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 Wealth District- T 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." r The applicant must c 1 10 al quired i7ections. Complete drawing on rev rse side. i Signed ��C/ Title:- – Date: 3 l� OR DEPARTMENT USE ONLY Application Accepted by Date C' : Area--&'? _ r �� Pit or Grout Inspection by Date 3r 11�" final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. + EH13-Z41REY.1i851 1 ,�� , TO� g "^IZp EH 14-28 7 E Ck k