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APPLICATION FOR PERMIT �g( � `.,: .i SAN JOAQUIN LOCAL HEALTH DISTRICT W.. 1601 `E. WAZE" TQIW.AV•E. STOCKTON, CA � 3 ,�: til Telephone (209) 466-6781 .� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED; 7 C1 41 c.- (Complete in Triplicate) e Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the w�yr1�`� �esc ��A�ppplication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wefllpump and the Ru`fesft� f�in Joaquin Local Health District. Job Address 140 IV kill 4111 W City<�f'Size PM Owner's Name V JAAddress & II c( ___ Phone Contractor �-� Address O �� k [ �f Z7 License No, f�Z ,3 Phone TYPE OF WELL/PUMP: NEW WELL F1 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 17 SYSTEM,REPAIR ❑• OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER ONES " DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL ;OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION StPECIFICAT10NS ❑ Industrial ❑ Open Bottom ❑ Manteca y Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy "t 'Type of Casing Specifications I'1 Public ❑ Other F1 Delta Depth of t,roufTeal Type of Grout "` I I Irrigation _..Approx. Dep I Eastern Surface Seal Installed by Repair Work Done L7�Type of Pump � . H.P. S I State Work Done Well_Destruction ❑ Well Diameter r -Sealing Material (top 5p') ..._ Depth s � Filler Material Beiaw 50 ') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 RF?AIR/AODITIONX I DESTRUCTION I I (No septic system permitted if public sewer" available within 200 feet.) Installation will serve: Residence_ Commercial— Other, I (i Number of living units: Number of bedrooms1 {� Character of soil to depth of 3 feet:_ SEPTIC TANK ❑ Type/Mfg ` Capacity-' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line U • 1 SEEPAGE PITS 1 ) Depth Size Number r SUMPS L_; 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 per in ch manner as to become subject workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the Sowing: " certify that in the orman f e work for which this permit is issued, I shall employ persons subject to workma 's compensa- tion laws C 'fornia IJ The ap ice cal or all r uir omplet drawing on r � ��„ Sign (.c�/ 6Title: %%f[�L��- Date: FOR DEPARTMENT USE ONLY Application Accepted by - Date rea Pit or Grout Inspection by Date Final Inspection by Date P-/cf�Slr Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1123-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +. EH 4-28 EH 13-24 IREV.r/H 5) r ^Z�J. 7 , 1 i