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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICTr 1601 E. HAZE I ON AVE., STOCKTON, CA D � ;�S19,1;� ��. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JUN rte ` ' (Complete in Triplicate) HfA PP 4 P Wrh1tN1Z1�1f1 �L LTH Application is hereby made to the San Joaquin Local Health District for permit to construct and/or instal[the es l ppGcation is made in compliance with San Joaquin County Ordinance No.548 for sewage or No. 1862 for well/pump and the RuidRIMM��db San Joaquin Local Health District. Job Address �J� zE=_i ��/7/�C� �7`• City Lot Size PM Owner's Name Mn eme2 /C /CF Address Phone A .,v1 , �.�-e ,arm Contractor 1"1��/ri �� .� AddressLicense No.*M4/1—Phone Z i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION )de,1541/, G�STEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial '�L— L `❑-'Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private 17Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public 4 ter. C7 Other ❑ Delta Depth of Grout Seal Type of Grout - I I Irrigation _--Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Ty_pe of Pump _5Z?, 7 H,P. _�= State Work Done f_. Well Destruction ❑ Well Diameter Sealing Material Itop 50') AVIrW Depth Filler Material {Below 501 TYPE OF,SEPTIC WORK:-- NEW INSTALLATION l] REPAIR/ADDITION l I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet) Installation will serve: Residence.— Commercial_ Other Numb�r•of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTICrTANK ❑ 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 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.folloW.ing;;,f certify.�hat in the performance-of the.work_for—Which-this permit is issued, I shalt not-- employ any person rn such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: 1 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 applicant qr I requ' a s. Cohiple'ti- Z_raw- ing-dn're- srs tide. ,,_Signed_XFOR DEPeMTMENT USE ONLY Application Accepted by �, Date Area Pit or Grout inspection by / Date Final Inspection by Date 1 F Additional Comments: © Stk 466-6781 Ll Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE iNFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED 8Y r DATE PERM17'NO. .y + EH 13-24{REV.I/H 51 35 C 1 f '(0 49 a s EH 1428 YY// l