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2. r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 4 ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . to 4 ! (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. Jab Address eQ �( V6 City h Lot Size PM Owner's Name AC& Address Y e � � C 1 � �2 � Contractor pr e,- ICe4 J 14 c-Address (�75 0 � License No.� PhoneO?F� d�a7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ +e,1- ;10�ef PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER _,- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE. h �1`Iv-"+ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS v INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L,rk � le) ❑.Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well asing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I dr; t I ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout' 4 4 t, d i ❑ Irrigation _._Approx!Depth 71 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump; H.P. State Work Done Well Destruction ❑ Well Diameter+ Sealing Material Itop 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence—A Commercial Other Number of living units: Number of bedrooms � I 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 1 I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: r Well Foundation Property Line .{ *. SEEPAGE PITS ❑ Depth t� 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 II rules and regulations of the San Joaquin.Local Health-District. 1 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 I 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 law of California." - i The plic nt ust calf f a aqui inspectioris. Complete drawing on reverse si e. , �� �/�!`4 >� a't4 Date: l /7 Signed Title: T_ R M SE ONLY _ ` Application Accepted s Date Area CFwece� Pit or Grout Ins n by Date Final Inspection by Additional Comments: ;IR--Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑-Tracy W15-6314( Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 V FEE AMOUNT DUE . AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH -13-24(REV.i/H5) _ 3S C —71 +428 +� "=RY