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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 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I Application is he+eby 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 I Local Health District. �` Gfd.']M1�w Job Address I Z37-030 0l5 City Lot Size PM � J�] _ T /� p /� �. Owner's Name z /OS� ,� S &G 1'/ D Address 0 ( / IP `l*h/'O 7`3 V9 Phone Contractor S e6try')I Address2 Z✓ PtlG SA License No� s 2Z P e IYE1,70 ;E TYPE OF WELL/PUMP: NEW"WELLA WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X/J')07/rO/'If1, W ellfi DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLD. 7G PROP. LINE FOUNDATION! AGRICULTURE WELL &&-- OTHER WELL PITS/SUMPS 4 v7_17 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFI rJ5 ❑ Industrial ❑ Open Bottom CP Manteca Dia. of Well Excavation Dia. of Well Casing Ll Domestic/Private Gravel Pack Tracy Type of Casing VL ' 0 -Specifications M Public *ype er n Delta Depth of Grout Seal 20 Type of Grout�m clf�C�fo byre , I Irrigation - r x,-Depth I I Eastern Surface Seal Installed by e �� U� 1 Repair Work Done ❑ f PumI H.P. State Work Done P P Well /yDestruction ❑ Well Diameter{' E Sealing Material Itop 501ra ZO/ ` wdl-f Depth = - Filler Material IBelow 50'} &INe 2 TYPE OF SEP 1C WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION f I (No septic system permitted if public sewer is O available within 200 feet.) O Installation will serve: Residence > Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: A Water table depth y SEPTIC TANK ❑ Type/Mfg I 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 I FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS I I Depth I Size Number 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. v Home owner or licensed agent's signature certifies the following: "I certify that in thio performance of the work for which this permit is issued, 1 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 persons subject to workman's compensa- tion laws of California:"�w`" The applicant st call for all required inspections. Complete drawing on reverse side. Signed X Title: NA - Date: 2-,y— FOR DEPARThAENT USE ONLY Application Accepted by,Z4_4c. 9 Date ` Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: © Stk 466-6781 ❑ Lodi 369-36211 ❑ 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 R(EMITTED C K 41 RECEIVED BY DATE PERMIT'NO. t.EH 1324(REV. /n 5 '� ) `-"� /,q .`�0 I.-�� M EH a-Zfl G� h vi rQ