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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I 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 Z/2.03 ,iI /C� C-6 V� �C a� City A+ Lot Size � PM � / STjOG i�pN Owner's Name a ZG r Address 1;'/f G! 4C � 2.iQ(�/rc C /cp Phone -(5 s'z' Contractor t/ i� 0 Address/'O 19O 04 License No 3 2 7 3 P-C Phone 3 3 V- y?Zd T TYPE OF WELL/PUMP: NEW WELL >( WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM,REPAIR-1 OTHER, ❑ i DISTANCE TO NEARST: SEPTIC TANK iSEWER-LI ESDISPOSAL FLD� �= PROP. LINE --- i FOUNDATION "'AGRICULTURE WELL OTHER WELL INTENDED USE TYPOF WELIr PROBLEM AREA} VONSTRUCTION SPECIFICATIONS, , ❑ Industrial ❑ Ope`ri`Bottorn+ V Aanteca Dia. of Well Excavation i Dia. of1Well Casing /Domestic/Private WGravel Pack ❑ Tracy Type of Casing 5-1'�4 C L ! Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _1 L Type of Grout C Cm ❑ irrigation I --Approx. Depth ❑ Eastern Surface Seal Installed by G7161i Repair Work Dore ❑ Type of Pump H.P. 1 !(� - State Work Doe Well Destruction ❑ Well Diameter I Sealing'Material (tap 501 V Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Ii I available within 200 feet.) ti Installation will serve: Residence— Commercial_ Other I i e, Number of living units: Number df bedrooms Character of soil to a depth of 3.feet: Wat r able depth SEPTIC TANK ❑ Type/Mfg }t �. Capacity No. (Compartments PKG. TREATMENT PLT. ❑ Method of Disposal " l ii Distance to;nearest: Well, gFoundation Property LirSe410 7K �U • LEACHING LINE ❑ No. & Length It #_ lines *`"1' � _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property L ine` r V t f SEEPAGE PITS ❑ Depth Se Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ YY c 11f l 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. i I Home owner or licensed agent's signature certifies the following: "I certify that ir5 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-."Contractors 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 6rsons subject to workman's compensa- tion laws of California." The applicant must call for II required inspections. Complete drawing on reverse side. r Signed X— mob ' Title:_( '�(L"M./�-�. Date: FOR DEPARTMENT USE ONLY Application Accepted by Date4g d Area Pit or Grout Inspection by Date Z� Final Inspection by Date i Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmen;al Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEEi INFO AMOUNT DUE AMOUNT REMITTED ASH 4 RECEIVED By DATE PERMIT N . + EH13-14(REV.i/A 51 EH t4-28 i