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f ' k APPLICATION FOR PERMIT R SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA a 19-'0 Telephone {209) 466-6781 W [PERMIT EXPIRES 1 YEAR FROM DATE ISSUED OA r I (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. �] r[J O�00 0 a� L o Cit rt? Lot Size J�� Address y PM A D,�retw#I, p%111 MO4Q174 CA 966'3543 Owner's Name7go" V �i f [S owEi Address 436 aP►POS� ��.� ��j�yPhont'�a9 S r'Z^. ► Contractor G C: . *fily risk S�, Iry qy 8 Address 4 License Nv.Yb 3 Phone 1 G TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 11 DESTRUCTION ❑ f 1 mpM+ivrr46 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ® 1M4 1/ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLiSO PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing n. D Domestic/Private $1 Gravel Pack ❑ Tracy Type of Casing-5 YO�y _ Specifications F1 Public Cl Other H Delta Depth of Grout Seal q,6f*X I+0 Type of Grout ,rNIP ! !*I Ir�igatniq�,,�� 30 .-Approx. Depth l I Eastern Surface Seal Installed by_CQhIrAc ryr C(�Wf1�.1t Repo rCWork Done ❑ Type of Pump H.P. State Work Done r Well Destruction ❑ Well DiameteJr Sealing Material (top 50') j Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR/ADDITION I I DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) 'V Installation will serve: Resid ce 'Commercial_ Other Number of living units: mber of bedrooms Character of soil to a depth of 3 tee �` Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments (� PKG. TREATMENT PLT. ❑ Method of Disposal Q Distance to nares Well Foundation Property Line LEACHING LINE ❑ No. & Length�Iine Total length/size FILTER BED ❑ Distance to nll Foundation Property Line r SEEPAGE PITS { I Dept Size Number SUMPS Cl ance to nearest: Well Fo anon Property Line DISPOSAL PONDS I 1 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 ' rules and regulations of the San Joaquin Local Health District. 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." i! The applicant must call f al1 required inspections. Complete drawing on reverse side. Cs e Q t-0elcA "' V t'g! �- Signed XX �1 r� L 4 t Title: r01 PcTCrewl,0 !F�' Date: RDEPARTMENT USE ONLY Application Accepted by Date Area � 9 � Pit or Grout Inspection by i Data Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmi ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.; CA 95201 FEE, AMOUNT DUE AMOUNT REMITTED INFO RECEIVED BY DATE PERMITNO. + EH 13-24(REV.r/115) EH 14-2e C'9Q p 4