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" y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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/pump and the Rules and Regulations of the San Joaquin Local Health District. , Job Address '247e Al ;-e_Q City S/1[ Lot Size PM Owner's Name 182,e">6 704mddress tole, &24 Phone Contractor's Name lymeemAA Z1ow&.License No. Phone I TYPE OF WELL/PUMP: NEW WELL El,_ WELL•,�R^EPLACEMENT, El DESTRUCTION ❑ PUMP INSTALLATION �R-M STEM REPAIR ElOTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I IQ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other } ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by ► Repair Work Done ❑ Type of Pump i50.13 H.P., 25 State Work Done A&&& 7��L1 l A15 � Well Destruction El Well Diameter � Sealing Material {top 50'1 � � Depth s Filler Material (Below 501yl I f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1 i available within 200 feet.) zi v ": J r Installation will serve: Residence_ Commercial_ Other Number of living units: Number ofabedrooms !� ) Character of soil to a depth of 3 feet: I I 1 i Water table depth � f SEPTIC TANK ❑ Type/Mfg i Capacity r ` No. Cor�ipartments , PKG. TREATMENT PLT. ❑ r. f'. } Method,f Disposal Distance to nearest: Well Foundationr-,-—_._j Property Lina`" YY 4 I z,- LEACHING LINE ❑ No. & Length of lines I �wJ Total length/size FILTER BED 0- Distancelto nearest: Well 4 {iFounation 1 P€operty Line I I_ - I SEEPAGE PITS ❑ ntu th ► ' SiNumber SUMPS I E] +Distance)to nearest: Well Foundation Property Line _ ' DISPOSAL PONDS � ❑7+ "'�.7 [ i hereby certify that I have'prepaaXred this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations ofthe San Joaquin Local Health District. Home owner or licensed_ageWt'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 wo for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." r� t The applicant m r all squire s ons. Complete drawing on reverse side. GJ Signed X Title: Date:. FOR DEPARTMENT USE ONLY Application Accepted by Date � Area Pit or Grout Inspection by Date ) Final Inspection by lit i / Date 3 3 CI 3 Additional Comments: g ❑ 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 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH �g + EH 1324(REV.10/831 3� 1 /-1 EH W28