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r4f:- , +� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZELTON AVE., STOCKTON, CA Telephone • (209) 466-6781 PERMIT EXPIRES 1 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/ um and the Rules and Regulations of the San J ! Local Health District. p p e9 Joaquin Job Address log) I^P G 1/ rr { -Orly t� City OL a' Lot Size Igo HU , PM �G/D 0 Corms Owner's Name j'11cc- cr,rQ. !i nv�rcnrn<ifi Address k ione Il$c0f fc + ZD�t �lYB� p y d I H�67H C Contractor kr'rS5rte'�` C5g fi Address_7EVE License No. k;��020 Phon, of- V Y�� rb {� 4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION� PUMP `' INSTALLATION ❑ M""r;fr`1'25 L-'-4' SYSTEM REPAIR ❑ OTHER ❑ II' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ �l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ MantecaDia. of Well Excavation F Dia. of Well Casing n ; ❑ Domestic/Private XI Gravel Pack ❑ Tracy Type of Casing S l pecifications ❑ Public 11 Other [I Delta Depth of Grout Seal ' i' ❑ Irrigation ) ' Type of Grout RMAJ ,a + �4pprox. Depth F1Eastern Surface Seal Installed by cry w4C fi Repair Work Done ❑ Type of Pumpt n H.P. h� ---�--- State Work Done Well Destruction Well Diameter `�n Sealing Material (top SO') �' 1 Depth 1 Filler Material f Below 50') 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 Commercial— Other ` Number of living units: Number of bedrooms 'i Character of soil to a depth of 3 feet: t I Water table depth SEPTIC TANK ❑ Type/Mfg;ICapacity No. Compartments f PKG. TREATMENT PLT. ❑ y j. 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 ❑ Depth 61 -SizeI Number "- SUMPS is ❑ Distance to nearest: Well DISPOSAL PONDS El Foundation Property Line 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 A ' rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the followin g: "I certify that in the performance of the work for which this permit is issued, !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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must #for all re fired in ctions. Complete drawing on reverse side. Signed x Title: r"�i� i a P Date: j FOR D RT �Z SE ONLY Application Accepted by z-2" Area Date Pit or Grout Inspection by S Date6161-2 Final Inspection by Date a �� Additional Comments: E ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca '823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environm11 ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. A + EH 18-24(REV.lie 5) EH 14-28