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APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES-�I.YEAR FROM,DATE.ISSUED t , (Complete in Triplicate) I tFv 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.5.49 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ' r Job Address _Ci -,,Lot Size 'Owner'sName`��YYVg��Address Phone _ f Phone Contractor � �� g� Address�,� icense No.GfJj1--�pi� e�lJ.L TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ i -DESTRUCTION - ---- —'PUMP INSTALiATkOtt! ❑ ,,,r 5YSTENMEPAIR'-I]--- OT ER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER^LINES DISPOSAL FLD. I PROP. LINE AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OFxWELL PROS EL M ARE), CONSTRUCTION.SPECIFICATIONS � ❑ Industrial ❑ Open Bottom El Manteca� Dia. of Well Excavation Dia. of Well Casing ❑ Domestic Private ❑ Gravel Pack, ❑:Tracy Type of Casing Specifications ❑ Public { ❑ Other.-:'_„ ❑;Delta Depth of Grout Seal Type of Grout ❑ Irrigation;' i" ° Approx. Depth ❑ Eastern Surface Seal Installed by I� Repair'Wor� Done ElType,of Pump�"'6 *" M H.P. State Work Done Q AI 5' V11ell Destruction )C Well Diamer ;� Sealing Material (top 50'1 Depth Vet=7.'S laJ= D'`42 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is $� available within 200 feet.) V Installation!will se esidence_ Commercial— Other Number otliving units: ber of bedrooms t Character of soil to a depth of 3_f_eet " Water table depth V l 1SEPTIC TANK ❑I Type/Mfg �'_ R Capacity T' No. Com r ments 1 11 PKG. TREATMENT PLT. ❑ 1 Method of Disposal \} s \v� .� Distance to nearest: Well Foundation Property Line LEACHING L NE ❑ No-&Lerigth�af.lines Total leng e FILTER BED j ❑' Qis a ce`iapnea�est: Well Foundation �' ' Property Lr SEEPAGE'PITS 01,-, Depth Size Number t * SUMPS __ O D4,.)ce.to-nearest: Well---`- �4�r-�FoundatioA7� Property Line DISPOSAL ONDS a I hereby certify that I have'prepared this application Ad that the work will be done in"accordance with San Joaquin.county ordinances, state laws, and x rules and regulations of the San Joaquin L'ocal�HealthI District. ' d��.�q d ., 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 wQ?kman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I cex fy that in the performance%f thework for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." - �.t ti / g� The applicant o call req i s ctions. Complete drawing on revers side. Signed X , Title: Date: { FOR DEPARTMENT USE ONLY F _ Application Accepted h 7 r Date Area Pit or Grout Inspection by +Dapte Y` -rte _ Final Inspection by Date Additional Comments: ;-04) ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 I , INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. r F + EH 13-241AEV.1/R 5] 55 fi -. / —LIOZ ' I EH 14-29 , L7/�