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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL ON AVE., T 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. �j ti� /� Job Address . o � R` `^'� City Cze_er Lot Size ��/ :21 PM Owner's Name Address 2011 91-15 /tr � �' Phone 2 6,181—Llf Contractor e " 0",_Vq v ,/License Na. 1"c <5 Phone 71W-2-7D TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER Elf, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � DISPOSAL FLDA50 PROP. LINE 0 FOUNDATION 'AGRICULTURE WELL7— OTHER WELL J PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public Cl Other R Delta Depth of Grout Seal Type of Grout I rrig�tion _Approx. Deptb I I Eastern Surface Seal Installed by c �J Repair Work Done 4P---Type of Pump H.P. 16 State Done Well Destruction ❑ Weil Diameter Sealing Material (top 501 Depth Filler Material (Below 501 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other PPAA V M EN T Number of living units: Number of bedrooms ��ra,Eli Character of soil to a depth of 3 feet: Water table yy ppeppt Jft1F19fofi" M SEPTIC TANK ❑ Type/Mfg Capacity No. Comp ts PKG, TREATMENT PLT. ❑ Meth CAW* W Distance to nearest: Well Foundation Property Li I'I`I�!' VICES ��I��IR`Il�k�twb.�l'4P k��,Ar►,.i►�l7�VI�1�'1n LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS; _L1 Distance to-nearest:., -Welt Foundation—..Property Line . s DISPOSAL PONDS 0 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 applicanust I! f all requi inspections. Complete drawing on reverse side. r Signed X W4Title: ��[.xti..t/ Date: YZIV& IFDEP R7MENT USE ONLY ` Application Accepted by Date[ _ J� Area Pit or Grout Inspection by Data Final Inspection byz>Ll Dat s 2-1 -cj/ Additional Comments: ❑ SO: 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, Silk., CA 95201 INFO AMOUNT DUDUE t7 �AMOUNT REMITTED C SH RECEIVED BY DATE /PERMIT-NO. +.EH 53-24{PEV.i i N si 1 EH 14-26 a