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ya APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE JT Q.N AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the w qh�l�r[ain`�9VnXA TMf ALLT anon is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Ruesrl ��a 1s}�� BAn Joaquin Local Health District. c - 1 l 01 Jab Address �': 9 City' _' 1 Ali A Owner's Name 1 y t Lr t Address Q�)AFC, Phone J Contractor Address chok 1927 License No. ��ZPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR Qr— OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public s F Other f.-1 Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation _Approx. pt I 1 s Detern Su V e Seal Installed by _ Repair Work Done Type of Pump H.P. State Work Done Destruction 1171 WellWell Diameter Sealing Material (top 50'i ~' Depth Filler Material (Below 501 _ TYPE OF`SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION € I lNo septic system permitted if public sewer is f ' �'.:I 1` available within 200 feet.l 00 Installation will serve: Residence_ Commercial____ Other 17 Number of living Knits: 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 II'l< DistanceJOihearlst:; Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number 1 Nk SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,,state-laws, and _ 1 rules and regulab an Joaquin Local Health District. . I V??�' i Home owner lcentsed agen s signature certifies the following: "I certify that in the performance of the work for which tl iWpermit ii iss suit,I shall not employ any rson in such m ner as to become su ' t to workman's compensation laws of California."ContractorYll-iringWir srili-contracting'signature certifies the ollowin s: "I c if at i th o ne of the work for which this permit is issued, I shall employ persons subject to workman'.?s.compensa- tion laws o Califor t The applic ni .allfo all re it a rowing on rev e Signed X Title: r Date: FOR DEPARTMENT USE ONLY I Application Accepted by _ I / � Ea _ Date f 7_-,Pal Area�- Pit or Grout Inspection by Date Final Inspection by Date J 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 FEE a INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT*NO. +.EH 1324(REV.,/n 5) 5 EH 14-28 "23 \p IS