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APPLICATION FOR PERMIT (� i SAN JOAQUIN LOCAL HEALTH DISTRICT ~1 1601'E. HAZEL T ON AVE., STOCKTON, CA VAR 1184 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN LOCAL (Complete in Triplicate) HEALTH DISTRICT 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. J Job.Address Size PM Owner's Name A M I L CG 2 CI1:U EN ESAddress S� 6 Y 4& t'', Phone 9S-1— 2 ,f Zr Contractor's Name one A11,019-5, License No. CL .SAI ZZ Z 3 73 Phone 2 S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ .' PUMP INSTALLATION ❑ SYSTEM REPAIR i____ OTHER ❑ 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 _ -w.:❑ I dustrial•-- ,- F ❑-Open=Bottom -D Manteca Dia.'of Well Excavation- `Dia�11 Casing omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation JApprox. Depth 4.` Eastern Surface Seal Installed by Repair Work Done P" -Type of Pump H.P. Z State Work Done Well Destruction ❑ Well Diameter Sealing Material .ltop 50'1 s Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑- DESTRUCTION ❑ Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i I hereby certify'that'l 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 lice 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 pe n in$-I nner as to became subjec orkman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the (lowing:"I ce i that in the an of a work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws f Calif rnia." e Thea licant m t I req ed ' mplet drawing on reverse id . Signe Title: Date: 2' 7-,f4l, - 7 FOR DEPARTMENT USE ONLY Application Accepted byGl Date l� Area Pit or Grout Inspection by Date Final Inspection by Hate Additional Comments: ❑ Stk 465-6781 ❑ 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 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. - * +EH 13-24IREv.10/831 �6,5 EH W26 3�S% %4