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APPLICATION'FOR PERMIT } SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON-AVE., 'STOCKTON, CA '. Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED F - ,---��. - a- 11trrk;10tfor Q plete in Triplicate} 3 4 5.2 S. ticr�,c r�+i` q_ / 2 Application is hereby made to the"San Joaquin Local Health, 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 Re uulations of the San Joaquin Local Health District." I'F Job Address M4• CDRAIER pr- /A/%F IAVV City Lot Size PM � ) ,zoo Owner's Name �+ OPRL E$ Address .Z(P& J46 GLykjob b Alk Phone Ba 2-Sb I � C Contractor IP.L, Address J+�' 7 CA Licens�A� 11 3- pinek ' 0 "dor k 5. �r�a.JJ TYPE OF WELL/PUMP: NEW WELL�j WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL_4ZV' PITS/SUMPS �p I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y I , J ❑ Industrial LJ Bottom L1 Manteca Dia. of Well Excavation ti , Dia. of Well Casing 4 e Gravel Pack ❑ Tracy Type of Casing 576 FCf Specifications i f I Public C1 Other 171 Delta Depth of Grout Seal Type of Grout-jCG. " 1 1 Irrigation ".-Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filter Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted if public sewer is j available within 200 feet.i i Installation will serve: Residence_ Commercial'_ Other Number of jiving units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments l h PKG. TREATMENT PLT. ❑ ,� Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS I I Depth Size Number ` SUMPS LI Distance to nearest: Well Foundation Property Line '' r DISPOSAL PONDS ❑ 1i 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 l employ any person in such mariner 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, I shall employ persons subject to workman's compensa- tion laws of California." The applica must call for all required inspe ions. C mpl t drawing on reverse side. { Signed .Title: 1�� C ate: I FOR DEPARTMENT USE ONLY Application Accepted by 7�YDate 4-3 U Area n � I Pit or Grout Inspection by Date --z- -,P Final Inspection by Date - I Additional Comments: a ❑ 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 95201FEE f INFO AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'NO. + EH13-24(REV.tiK5) 4�2L_V EH t4-26