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A APPLICATION FOR PERMIT _ I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE1,7lON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r '+ (Complete in"Triplicate) - rri 3'. r w ��- 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 Ryles and Regulations of the San Joaquin Local Health District. 4$" x ' " f ! .. F Job Address Ci : , ' i Size'so��Vit PM' s city ^� Lot Size Owner's Name,5_57,Fle 110A ow Address l S/� �� - Phone Contractor il/9, Address AX �X S7a2� License No. �333.19 fPhvne TYPE OF WELL/PUMP: NEW WELL ❑ ilw_ELl.REPLACEMENT'"❑— —DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ } DISTANCE TO NEAREST:-SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE c FOUNDATION"""'"""^"" ""AGRICUETURE WELL'v" OTHER WELL 1 PITS/SUMPS INTENDED USE :TYPE OF WELL PROBLEM AREA (CONSTRUCTION SPECII_IICATIONS ❑ Industrial El Open Bottom '❑ Manteca Dia. of Well Excavation ��. �^ Dia. of Well Casing ❑ domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing } Specifications ❑ P blit E Other v- :[_1 Delta Depth of Grout Seal I Type of Grout, y ❑`Irrigation ` Approx. Depth ❑ Eastern Surface Seal Installed by , Repair Work Dane ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material'(top 50') Depth I Filler Material (Below 50'0 TYPE OF SEPTIC WORK: NEW INSTALLATION L7-,,REPAIR/:ADDITION ❑ DESTRUCTION, (No septic system permitted if public sewer is u - V % °3 i1%\', , I .,,,�._ available within 200 feet.) Installation will-serve: Residence� Commercia` Other I Number of living.0 nits: -y— Number of bedrooms- i Character of soil to a depth of�3 feet: � f W_ater'<tabte-depth— SEPTIC epth-- r SEPTIC�TANK ❑ Type/Mfg- ,' Capacity No. Compartments PKG. TREATMENT PLT. ❑ ; * Method of Disposal D#ista ce to nearest: Well * Foundation Property Line LEACHING LINE ❑ No. Length of limes Total length/size _ f FILTER BED ❑ Distance to nearest: Well Foundation Property Line I s SEEPAGE PITS rl Depth Size• Number i ' SUMPS =��`` ❑\1Distance to nearest: Well Foundation Property Line s DISPOSAL PONDS ❑ 4 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 Sari Joaquin Local Health District: Home owner or licensed na ag g agent's.siture certifies the followingk � :�'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."Contractors 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." I # } q The applicant m call for all required.ins ctions. Go lete drawing on reverse side." i ^� S. Signed r ; Title: ` Date: FOR DEPARTMENT USE ONLY Application Accepted by Area Pit or Grout Inspection by - - Date Final Inspection by r1)atelel07 Additional Comments; !2k .� 97 ❑ Stk 466-6781 le ❑ Lodi 1369 "-�❑ Mant ca,823-7104 ❑ Tracy 8355-6385 1 Applicant- Return all copies to:.Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEECK t ^a" _iNFO AMOUNT_bUE. ,AMOUNT REMITTED— CASH�-° RECEiVED-BY—.�..,_ DAT.E�.. ., PERMIT NO.- -- + EH 1324(REV.i/e 5) ��`.Q'J '":• ��+•r ` r.. 13 �S�"' . EH 1426 ; l "