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APPLICATION'FOR-PERMIT_ SAN JOAQUIN LOCAL HEALTH DISTRICT" 1601 E. HAZELTON AVE.; STOCKTON, CA Telephone (209) 466-6781 4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j - (Complete in Triplicate) { Application is hereby made to the San Joaquin local Health District for a permit to-construct and/or install the work hetein 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. ` %,! ` ' //}} A. y, 2 Job Address flilec ('0.9'D `esk l"nLltt5�ar o- �vt�Q.c a.95331 City Lot Size PM Owner's Name yt C0 �Ka K11 �L}r�"`�Address 54-0l�e IS-1y 7s a��t� ra e v '' ; p Contractorye' a'cx hrA � Address��/� d JY License No + `Phone 9� 7�3-9733 TYPE OF WELL/PUMP: j NEW WELL K WELL REPLACEMENT ❑ DESTRUCTION ❑ ;, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 LlIndu'strial `�� w r�ElOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel{ Casing ❑ Domestic/Private, N, 1`9�Gravel Pack ❑ Tracy Type of Casing JQ G SpecWications ❑ Public " ' El Other thr I ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ;L5-Approxl Depth 11Eastern Surface Seal Installed by e I Repair Work Done ElType of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') I IMP41" It'd15 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 'ill serve: Residence,� Commercial Other Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Method of Disposal PT PKG. TREATMENT L ❑ _ Distance to nearest: Well Foundation Property Line ` ••• rf LEACHING LINE 11No. & Length of lines Total lengthJsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ 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 a 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 f 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 c I for all required i coons. Complete drawing on reverse reverse side. Signed Title: �� a:�l � Date: D R E ONLY r Application Accepted by < Date Area_ -- Pit or Grout Inspe n Date 7Final Inspection by Date 'f � Additional Com ts: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6305 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 RECEIVED BY DATE PERMIT'NO. INFO CASH t + EH 13-241REV.1/e5) - /�� cj7•• 5 EH 14-28