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APPLICATION FOR PERMIT ?R'° SAN JOAQUIN LOCAL HEALTH DISTRICT # 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED7 (Complete in Triplicate) �Qr Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein d+ 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 Regul� fSan Joaquin Local Health District. Job Addresst�l.�� _ i'IGc � U.f F'1ye Gv1U City rI Lot Size 40 aC/P5 PM Owner's Name DM61r1Address PD &n"C "OVt 5rt a Phone ��D$ ZI– D l" p g 6� Contractor 4xi evk t e� ev Address f_•��_ X 53C 546RiAMerl C/4 License No. 49100 Phone0g,&-o-1199 1p TYPE OF WELLlPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION *� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ` DISTANCE TO NEAREST: SEPTIC TANK 11719 r SEWER LINES DISPOSAL FLD. PROP. LiNE jffd2f FOUNDATION AGRICULTURE WELL OTHER WELL PiTS/SUMPS INTENDED USE TYPO OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 \ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing l� gDomestic/Private Gravel Pack ❑ Tracy Type of Casing D RV01 Specifications f"1 Public n Other, n Delta Depth of Grout Seal _ Type of Grout ea .CC rr ._,� I I irrigation Z�fApprox. Depth l I Eastern Surface Seal Installed by Su" Repair Work Done ❑ Type of Pump H.P. --State Work pone Well Destruction ❑ Well Diameter q i"Cle-s Sealing Material (top 501 L, Depth 7O! Filler Material (Below 501 TYPE. OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION 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— r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line 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 Heahh Diktrict. 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 mann6cas 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 ust 11 f r all required inspections. inspections. Complete drawing on reverse side. / _ P Signed Title: l' 1S`zi-�-� eLW�j C+ _,_— Date: %1 ► C C_"lV ?!�1►� C%-Ark- pv - hld tr1+r► p71 i,_. 1 FOR DEPARTMENT USE ONLY Application Accepted byk4Date r D Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 D Lodi 3BS-3621 ❑ Manteca 823-7104 0 Tracy 8354M Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE r INFO AMOUNT DUE AMOUNT REMITTED CK A CASH RECEIVED BY DATE PERMIT N0. rEH1124iR1Y.1/x5S Z447Vo 3�( EH 142E fZ f