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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 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 irrDistrict. _/ Job Address`l 30 001V Ace �T; (awst wo D.) 11401(o2 Horr. ity��c k Id Kot Size •3,"/, f 6 aGb[._ PM Owner's Namek)(2eO Ilut CO U sA AddresJZ00 541441 S 1 . N O f.1S91 aAI T>C Phon�713 6 F677 S Contract,V;i"%q(dG 1=Lt p12lLLl dress 16-76 b? CUNCoY2:� UiceC 57 4 $z• 3cl0 Phor1�` 1S' 6.Y57-661 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ `, ) PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER,$)' "V DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .50 DISPOSAL FLD.""1 PROP. LINE ( O FT FOUNDATION AGRICULTURE WELL OTHER WELOC Ir1 G-PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. ofWell Excavation � 2 S r>7 Dia. of Well Casing 4 I N El Domestic/Private Gravel Pack 11Tracy Type of Casing Vy G 510**' Specifications Scy,2fo F] Public ❑ Other P<Delta Depth of Grout Seal 20 �- Type of GrouemCN f- a E N 7. 1 I I lrri atign Approx. Depth 1 I Eastern Surface Seal Installed by 121 L(-F2 _ &�( N r 0 f '+V par(ir Wor Done Type of Pump H.P. State Work Done_ Well Destruction E Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is G available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number r SUMPS ❑ Distance to nearest: Well Foundation Property 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 subject 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applican t call for all required inspections. Complete d wing on reverse side. Signed X P11" ��I G[rt/IGIr 12�N- I Na itle: �OL©(-7' 1 5� Date: I 1 e?q C3 FOR DEPARTMENT USE ONLY {`� Application Accepted by Date 7 h v Area Pit or Grout inspection by Vh7h.1 Date 1'7d l Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mante 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20W, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY f DATE PERMIT NO. r ♦ EH13-24fREV.i/H5s S!3`� A 0 EH 14-26 ! `1