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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. f Io S t Job Address w��°N. City Cit n Y" Lot Size PM Owner's NameJOC,&YFa�i/ Address ��'►^*� Phone Contractor ce77tv1 e. c Address 282,5 C- /7yrtrx-e-57- License No. �Z�GB Phone`2�p y43-871.2 TYPE OF WELL/PUMP: NEW WELL 44,- WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 5C 190A.r1V9 DISTANCE TO NEAREST: SEPTIC TANK �. SEWER LINES NA DISPOSAL FLD. k� PROP. LINE✓,ZO4'f' FOUNDATION --A,^ AGRICULTURE WELL �� OTHER WELL PITS/SUMPS ooy.4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 'h ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Il Public ❑ Other n Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth ( I Eastern Surface Seal Installed by 75C4%,f* Repair Work Done ❑ ��Tfyoopa�eeeof��Pump H.P. State Work Done -V#LM Destruction Fd 'PVet1tiameter! G !0 Sealing Material Itop 50') CC, aeti�N Depth Filler Filler Material (Below 50') /'rf r� TYPE OF SFPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other I Number of living units: Number of bedrooms l Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments - PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line If LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS ! I Depth I Size _ Number SUMPS C] Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 appli nt mu t call for all required ins ctions. Complete drawing on reverse side. ��~hjc Signed X r.. h" Title: A• rC. -tq cc )r- Date: I I r� FOR DEPARTMENT USE ONLY Application Accepted by L\ Date Area Pit or Grout Inspection by �Date Final Inspection by 1 -4_ Date Additional Comments: ❑ 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 t 111 INFO FEE AMOUNT DUE ! AMOUNT REMITTED CASH K 9 RECEIVED BY D TE PERMIT'NO. 1 +.EHt3-24IgEV EH4-2B iJ o s i