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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., 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. Job Address aeaGon , 4?O N- Mzin S eek- City mw�ec.z Lot Size PM Owner's Name e&r—uy` tLk CPin -b" Address 5ZS CJI . `kic-c� �e'� a Phone 15 1-b7_4 A375S IJ1.155,oR BVek sk.S Contractor �te� ''� SiwrnS Add ess CA License No.M."i2-64— Phone lS-1-5;14 90 Ll- TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION C] 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 ElIndustrial ❑ Open Bottom F] Manteca Dia. of Well Excavation 10" Dia. of Well Casing ,�1 mit Gravel Pack ❑ Tracy Type of Casing SE At 'Py C Specifications ❑ Publics �'ZI- ❑ Other ❑ Delta Depth of Grout Seal "'1 s r Type of Grout ❑ Irrigation ---Approx. Depth . ❑ Eastern Surface Seal Installed by G&e Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter 4 It Sealing Material (top 501 Depth 1 40 Fee*"- Filler Material (Below 501 YPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installa will serve: Residence_ Commercial_ Other Number of livi nits: Number of bedrooms Character of soil to a th of 3 feet: Water table depth SEPTIC TANK ❑ Mfg . Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to rest. Well Foundation Property Line LEACHING LINE ❑ & Length of lines Total length/size FILTER BED Distance to nearest: Well undation Property Line SEEPAGE PI ❑ Depth Size umber SUMP ❑ Distance to nearest: Well Foundation Property Line D ASAL 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 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' the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." Theapplicant u 1 for r uir ions. plete drawing on reverse side. Signed t Title: mea $ Date: R EP T USE ONLY Application Accepted by Date A Pit or Grout inspe io ./ Date 12 J77LE6inal Inspection by Date/—/��j2- 7 � r Additional Comme ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 04 Tracy Applicant- Return all copies to: Environmental Health Permit/Services 16W E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 nINFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT''NO. EH 1324(REV.1/8 5) bfl3�O'* S_ ��O O Crj�- t4 EH 26 e/z' rO �S.�O,