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_ ------------------------- 16:3o --I6. 3O APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ' ' Telephone (209) 466-6781 4 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address /,L36 e- bra f 4.hb City Sia COLA," Lot Size PM 1 Owner's Name 'e Address pft h C 9$71 Rd• &r 40) Phone - Contractor 4YY!,ce- i 114V dress C�' � co Nd-d License No. � Phone I � TYPE OF WELL/PUMP: `i NEW WELL IX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION It SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC_ TANK _ SEWER LINES DISPOSAL FLD- PROP. LINE ; Y� EJFOUNDATION ' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED-USE- - TYPE OF WELL .PROBLEM AREA CONSTRUCTION PSPECIFICATIONS ❑ Industrial K Open Bottom ❑ Manteca Dia. of Well Excavation_1 O' s_ t Dia- of Well Casing a71v 1K Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 54,0_4 _ Specifications .,YV M Public N Other 17 Delta Depth of Grout Seal 5_01 � Type of Grout 3iA+uflACCfit K . Irrigation !.-Approx. Depth - I I Eastern Surface Seal Installed by R :` Repair Work Done JW Type of Pump H,P. State Work Done 14CAO too-d-:-New Tur1' p_ i Well Destruction ❑ Well Diameter Sealing Material (top 501 a Depth Filler Material tBeiow 50'f, TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION [ I (No septic system permitted if public sewer is available within 200 feet.) Insta11�1Dt !I serve: Residence_ Commercial_ Other ; Number of living un Number of bedrooms Character of soil to a depth o Water table-depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O r:. Method of Disposal ' Distance to nearest: Well undation Property!Line 1 LEACHING LINE ❑ No- &`Length of lines{ 4 5 length/size C) FILTER HED ❑ Distance to nearest: Well Foundation Pro ine i SEEPAGE PITS f I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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. a 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." The appli ust Call reqJ d i spections. Complete drawing on reverse side. 6 f ,q� M S�� Signed r le: 1 CIC{ut Data: Ow FOR DEPARTMENT USE ONLY V) Ilw10 -3 ApplccaliAccepted by Date Area Pit or Grout Inspectio by Date -71d,OYFinal Inspection by Date TJ _ Additional Comments: -P� Q Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 923-7104 ❑ 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 - -'GASHCK RECEIVED BY DATE PERMIT'NO. T ,5, �'/1 -� ' + EH 13-21(REV.1/w 5) /� r "� � � (� r77� } EH 14-2e j r