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r •po 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) Application is heteby made to the San Joaquin Local Health District for a permit to construct and/or install the ork herein described.This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and th �aryld Regulation of the San oaquin Local Health District. lrl �C9 Job Address .�� 1�/ Q r KCX —- Cityk-6 Lot Size �l ZX �'' PM Owner's Name pwI A% V% Address Soon No rC) Rd. Phone Contractor Address 'AJ.r:&&2 ./'I.�GQ�Y License No. f Phone Z TYPE OF WELL/PUMP: NEW WELL 04 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �...__,_. DISPOSAL FLO. PROP. LINE lyr FOUNDATION �f7r AGRICULTURE WELL �A OTHER WELLS PITS/SUMPS `7V INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing W Domestic/Private AMravel Pack ❑ Tracy Type of Casing_ FWD Specifications --LA Q [-I Public ❑ Osher F1 Delta Depth of Grout Seat �� Type of Grout 61e J I Irrigation AM-Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump _ 1 H.P. -7 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') 861 Depth Filler Material (Below-501 CZ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installatio serve: Residence Commercial _ Other Number of living uni t: Number of bedrooms 3 Character of soil to a depth o et: W a le depth SEPTIC TANK ❑; Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ! r Distance to nearest: Well Fo ion Property Line LEACHING LINES ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to st: Well Foundation Property Line i w SEEPAGE PITS I Depth Size Number r SUMPS L] Distance to nearest: Well Foundation Property Line tSTS OSAL PONDS ❑ f I hereby certify that 1 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 DIiltrict. 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 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 ust call for all required inspections. Complete drawing on 06- "'.0- Signed X Title: 6.1"'.0- Date: ;k `�—� FQDEP ENT USE ONLY Application Accepted by �� \c-L�]a.\L�\ Date "a� Area Pit or Grout Inspection by� - Date Final Inspection by p ate Additional Comments:Sb� . �rx.a� ^�► b ++ �� t ❑ Stk 466-6761 E) Lodi 369-3621 ❑ Manteca 823-7104 17 Tjacy 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 REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. *.EH 13-24 MEV.1 i n 51 EH 14-28