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3 O APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) r 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. Job Address �S City G Lot Size PM I Owner's Name ��If4 7U�� Address h c nn Rd• /07 OW-0 Phone p Contractor Aiyewam �i l tfws.xiudddress •U' Brz jud 4j License No. Phone G 7 l TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC_TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED-USE TYPE OF WELL. .PROBLEM AREA CON STRUCTION:SPECIFICATIONS 0 Industrial Open Bottom ❑ Manteca Dia. of Well Excavation y Dia. of Well Casing dew It Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Jt�f ° Specifications F] Public N Other n Delta Depth of Grout Seal `, Type of Grout a?0J 14 CCfi[ Irrigation -4Q---Approx. Depth, I ) Eastern Surface Seal Installed by [,, _ W Repair Work Done Type of Pump � H.P. State Work Done Mew Wey"' ew ump•• Well Destruction ❑ Well Diameter Sealing Material (top 501 i Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR)ADDITION [ I DESTRUCTION ( I (No septic system permitted if public sewer is available within 200 feet.) ; Inst alla r II serve: Residence— Commercial_ Other a ry r Number of living a Number of bedrooms Character of soil to a depth o Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well�-7— undation y Property"Line 1 LEACHING LINE )❑ No.A`L'ength of lines ' � � length/size CJ t j FILTER BED - ❑ Distance to nearest: Well Foundation Prop ine SEEPAGE PITS ('I Depth Size _ Number SUMPS Ll 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. t 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." W The appli ust ca`for req d i spections. Complete drawing on reverse side. tf Signed Ile: 4,vslcicri' Date: FOR DEPARTMENT USE ONLY Application Accepted by Date n Area o Pit or Grout Inspectio by Date r t �Final inspection byAWMDate 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 INFO AMOUNT DUE AMOUNT REMITTED �A/Ss�µ7` RECEIVED BY DATE DDAT�tE y/CXR PERMIT�'NNO. t EH 13-241REV.li>•61 ,V �► !/ L.1l�—TF(.1/+ �! / ` `^� O �� I i EH t4-2e 7 'i