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_ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL-1 ON AVE., STOCKTON, CA Telephone {209) 466-6781 plSr�t� PERMIT EXPIRES 1-YEAR FROM DATE ISSUED ��LT� (Complete in Triplicate) •q� PM�;y�p.L HE �� Application is hereby made to the San Joaquin Local Health District for a permit.to constru�ja Wk Niles l rein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 7862 for weirIp_ump a h Rules and Regulations of the San Joaquin Local Aealth District. I Job Address - 9 I,F _s fr1 eT _ _fit City Lot Size PM Ownerl;ls Name �1 d idGM Address �, 0- _6 Ctt A__� -a21:tPhone Contractor 6,+F address 3F9_5 OMe-G G:r. LicenseNo_Sl/1 q-.29 Phone 6-631-95" TYPE OF WELL0UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C] SYSTEM REPAIR ❑ OTHER $I 1)10r): OISTA'NCE TO NEAREST: SEPTIC TANK 7zr; SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL _—_ _ OTHER WELL _ _ •_ _PITS/SUMPS INTENDEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS " ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation — Dia. of Well Casing — ❑ Dorttestic/Private X11 Gravel Pack ❑ Tracy Type of Casing SGh 40 pVG Specifications 71 Public n Other n Delta Depth of Grout Sealf �t Type of Grout I I Irrigation �Approx. Depth I I Eastern Surface Seal installed by BrF 41JAtrr-y_ _, „•„• _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material(top 50') Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I 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 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Typal Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line _ F LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPiS 0 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. Homellowner 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.” Contractoes hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,f shall employ persons sbI q� �pt�tsa- tion laws of California." SAN JOAQUIN LOCXLT4A The applicant must call for ail required inspections. Complete drawing on reverse side. ENVIRONMENTAL HE'�LTHnD,VISION Signed Title: ,SPECIA%�t P d T FOR DEPARTMENT USE ONLY Application Accepted by Date rea II �_ Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk"- 466-6781 © Lodi 369-3627 ❑ Manteca 923-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health PermitlServices 1601 E. Hazelton Ave., P.O. Box 2009• Stk.. CA 95201 FEEa INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. gq �S r