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APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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 compliancewith 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 8808 FOX RQ City 1 ndi Lot Size PM Owner's Name JOE 1ANGUERM Address 16808 Enx RnadPhone 6648 Contractor Address License No. 309031-Phone727- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION XC SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE m i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 4-.,s '�►�1..y` _ ice`."- _. �� .yam � aF.�F_.r_r: _�:—t_. INTENDED USE TYPE OF WELL PROBLEM AREA'S CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation Dia: of Well Casing ❑ Industrial E) Open Bottom ❑ Manteca Type of CasingSpecifications El Domestic/Domestic/Private ❑ Gravel Pack ❑ Tracy I'1 Public Ll Other F1Delta Depth of Grout Seal Type of Grout - I 1 Irrigation Approx.-Depth.,._).-1-.Eastern Surface Seal_Installed-by - Repair Work Done kI Type of Pump ,C�r+" H.P. State Work Done sub- Repair Destruction ❑ Well D'iamefer "` Sealing Material (top'50'1 ; Depth Filler Material (Below50'1. ern TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIR/ADDITION l I DESTRUCTION I I aNailablettwithin 200 feet.) if public sewer is .30 Installation will serve: Residence_ Commercial_ Other 0 Number of living units: Number of bedrooms Oil � k Character of sail to a depth of 3 feet: Water to Capacity- No. Com1 } SEPTIC TANK ❑ Type/Mfg y f��;, PKG. TREATMENT PLT. ❑ Method ofr,gisposal i Distance to nearest: Well Foundation !-'Property Line - R /' MAR 2 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to neaiest: Well Foundation ° - Property Line EPdb'+R6fd ENTAL HEAJI H j I SEEPAGE PITS I I Depth Size Number = SUMPS ❑ Distance to nearest: Well Foundation - - -Property Line DISPOSAL PONDS ❑ -' 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. rtify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed a is signature certifies the following: "I ce employ any person in s anner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the followin I ertify 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 Calif i .' The applicant I or required inspections. Complete drawing on rev de. Si ned X Title: " Date: 9 FOR DEPARTMENT USE ONLY Application Accepted by C Date Area Pit or Grout Inspection by Date Final Inspection b�✓`�J/Q _ Dated " 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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO +.EH 13-24(REV.1/N 5) EH N-26