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" APPLICATION FOR PERMIT SAN JOAQUIN LOCAL-HEALTH DISTRICT ,rte 1601 E. HAZEL T ON kVE., STOCKTON, CA Telephone (209) 466-6781 ,; I PERMIT EXPIRES TYEAR FROM DATE ISSUED �S (Complete in Triplicate) NOV 1 DR7 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work ein[dQ$��'��ibettr�7fiispfidaLibte+ is g lr made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1$82 for well/pump and the Rules ee f`1' 4... alt Feguila4igrys�f�tflelSanoaquin Local Health District. { 1�Vlll :J ti Job Address Q City ze PM Owner's Name 35 + OFE + Address //Pew tt/ .YC 0 �i Phone Contractor essD0 ( .L� Z � License No. 7 Phone TYPE OF WELL/PUMP:. NE WELL ❑ WELL.REPLACEMENT ❑ DESTRUCTION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Oia. of Well Casing; ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications M Public n Other a ❑ Delta Depth of Grout Seal Type of Grout I i Irrigation Approx. De , I I stern Surface Seal Installed by Repair Work Done LY Type of Pump H.P. State Work Done_ F --. Well Destruction ❑ Well DiameterSealing Material [top 501 Depth Filler Material (Below 50') i a TYPE OF SEPTIC WORK: NEW INSTALLATION ("I REPAIRlA'DDITIDN i.l DESTRUCTION f I (No septic system permitted if public sewer is available within 200 feet.) .-- �. Installation will serve: Residence_ Commercial Other F I Number of living units: . Number of bedrooms + V Character of soil to a depth of 3 feet:_ �'' Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity--"--- apacity- \No':,Compartments PKG. TREATMENT PLT. ❑ S V1 of Disposal Distance to nearest: Well F undation 1-i4'a� � Property Line LEACHING LINE ❑ No. & Length of'li es Total length/size j FILTER BED' ❑ .�Distan�o_nearest: Well. Foundation Property Line SEEPAGE PITS� I I Depth s Size Number SSUUMPS� Ll Distance nearest: ' Well Foundation Property Line 11-ODISPOSAL PONDS ❑ I hereby certifythat I have p pp r 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. Homeowner or Ii ant'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 on in such anner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies th ollowing: "1 ce ify that in the performance of ork for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws f California." The ap Ica mus or require ns plate dra ng on r Signed Date: FOR PARTMENT USE ONLY t Application Acceptad by DateAre Pit or Grout Inspection by Date Final Inspection by 7Dat �l� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 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 FEE INFO AMOUNT DUE AMOUNT REMITTED C K 4 RECEIVED BY DATE PERMIT'NO. { /� t + EH13-24(REV.tiles) Fl J6&et �{J[�/y J/ ? I EH N-26 / _ fe— / k