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i 4a ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED i! (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 a Local Health District. Oq r M. V W� ! y Job Address A Ih City Lot Size PM I Owner's Name Sf�y MuDi Address l$O�i'( - ��►�� Phone(2-OV X63- ZS`63 j � i �r Contractor . e� !7N irJ�llI Address RV@� License No.�a �Phonr{mss Sn-05ZI I TYPE OF WELL/PUMP: NEW WELD ,; WELL REPLACEMENT ❑ DESTRUCTION ❑ ,! PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHEP �K Mr"dVAn' Cy), DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES x/190 DISPOSAL FLO. PROP. LINE '?L0_0 FOUNDATION 7� � AGRICULTURE WELL:!_/ t OTHER WELL >f00 PITS/SUMPS;� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y ❑ Industrial ❑ Open Bot tgm ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 11<Gravel Pack ❑ Tracy Type of Casing 5:.k. dfa PVC Specifications t � D� (`I Public C1 Ocher ❑ Delta Depth of Grout Seal udL N� Type of Grout j•0 I I I Uatj n qo -Approx` Dept I I Eastern Surface Seal Installed by _ �C ► O+A r lK T�epau VRv Doe ❑ Type of Pump it H.P. State Work Done)LAX 02 _ Well Destruction 17 Well Diameter -Sealing Material (top 50') reL44 Tw Sw a, \ Depth f Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence—1 Commercial_ Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:€ Water table depth SEPTIC TANK ❑ Type/Mfgi Capacity No. Compartments [ PKG. TREATMENT PLT. ❑ Method of Disposal Distance"10 nearest: Well Foundation Property Line i1 i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance-to nearest: Well Foundation Property Line I SEEPAGE PITS l I Depth Size Number ESUMPS Cl Distance-to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ )I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of the San Joaquiri Local Health District. 11 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 ust call for all quired inspections, Complete drawing on reverse side. Signed X Title: Date: __- Z� d/f'I /yle/ EN4�ARTMENT USE: ONLY 1 Application Accepted by Date /r Area Pit or Grout Inspection by ! Date Final Inspection by Datevvkl t/ Z I t ' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82 -7104 ❑ T acy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9 01 I (FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. + EH13-24IREV.s/N51 EK 14-26