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J .. A APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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. .��r Job Addresses erSh�R ON i ZG'rr±�L Cid, 671?c f5-' Lot Size _ PM Owner's Name U([L I c bls�i�GL'' Address « e2.4 f I+ �.v f� ,Q �L Phone�� i, Contract4ni ke`� I4� CV CC(! License No.Address 1J � �Tlj �(j y63—z Y63 TYPE OF WELL/PUMP: Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 02j 1W-7-WWA t o ° PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 8' P 40A) Gc� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESf DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 14 Dia. of Well Casing ❑✓Domestic/Private El Gravel Pack C1 Tracy Type of Casing d+�` Specificationsk1 Publicer ❑ Delta Depth of Grout Seal 11Irrigation —� Type of Grout L pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Q DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence Commercial available within 200 feet.) Other ; T� i Number of living units: Number of bedrooms (a w Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Proper Distance to nearest: Well Foundation Property Line y LEACHING LINE ❑ No:& Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Pro party 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 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 subjgct 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 muster all re uired inspect ns. Complete drawing on reverse side. Signed Title: vltrir.Ql Date: lU 6 ' « FOREPARTM T USE ONLY Application Accepted bys Date Area Pit or Grout Inspection b�Lo Date Fina! Inspection b Dat _ aAdditional Comments:❑ 5tk 466$781 ❑ -3621 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f�' FEE I AMOUNT DUE AMOUNT REMITTED INFO C RECEIVED BY DATE PERMIT'NO. +EH 1&24{REV.1/05) �O