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PLUG C,cJe Ai d. ;z T7 y APPLICATION FOR/PERMIT ick-co- SAN SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466=6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) !is 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 NOS- -5 , rf 45Nb City-5PCkldlff Lot Size PM r Owner's Name 1 +��, i�0��-S Address V19 q4h S 4 1q. L VII IiYP 69110j? Phone �1�—621; 1,.1 pp!!11 Il' Centractor� (/ p�f'� Addres Z5 . I`7 le 5k_ License No-67216b Phone_`7�' 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ d GlL 09M, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBI-EM AREA CONSTRUCTION SPECIFICATIONS +❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I-1 Public ❑ Other 1 F1 Delta Depth of Grout Seal Type of Group � �. I i Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by _ i Repair Work Done ❑ Type of Pump+ H,P. State Work Done Well yr-Destruction ❑ Well Diameter pp� Sealing Material Stop 50'1 �7if f ho Pr Depth �5 r7'C Filler Material (Below 501 TYPE OF SEPTIC WOM: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is G . ' available within 200 feet.) Installation will serve: Residence—+'Commercial— Other Number of living units: Number of bedrooms hi Character of soil to a depth of 3 feet: Water table depth P SEPTIC TANK ❑ Type/Mfg's Capacity NO. Compartments PKG. TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 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 t rules and regulations of the San Joaquin Local Health District. i 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, l.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 j certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applica ust call for all re 'red ti n�Complete drawing on reverse side. s�� 1Pr�o��f Date: V �ILe Signed X Titla.FOR DEPARTMENT USE ONLY a: s Application Accepted by A / Date Area Pit or Grout Inspection by /r,Q r . �u Date Final Inspection by Data a Additional Comments: tl5<a&C3 IN L ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63851 rVol Applicant - Return all copies to: Environmental Health Permit/Services 1601-E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 6 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. EH 24 i EH t4-26IREV.1iK51 v�