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APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT r _ 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) &p,p / 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. l d-tr �!, Job Address 0,60awbAgmt-c of Size D fflpm Owner's Name "� HW_&X70d&dT,,,, •�L " �A'cI`VR.Jr�(I14� Phone ru. -C=,,- ContractorQAAddress UL License No, d Phone & i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION r PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.-of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type ofy'Casing Specifications i f"1 Public 0 Other �', 11 Delta- Depth of Grout Seal Type of Grout I I I Irrigation —.Approx. Depth .' l-I Eastern Surface;Seal installed by ' Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction Well Diameter x Sealing Material {top 501 I Depth 3lot Filler Material (Below 501 Amr + TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAiRJADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is Q , available within 200 feet.) Installation will serve:' Residence_ Commercial_ Other �+ Number of living units: t .,Number of bedrooms Character of soil to a depth of 3 feet: s Water table depth �1 .SEPTICOTANK ❑ Type/Mfg (Capacity No. Compartments ., PKGtTREA TMENT PLT. ❑ : :w i Y Method of Disposal I Distance to nearest: Well Fourydation Property Line LEACHING LINE t 17-1s,.No,"8 Length-of lines t � Total length/size T FILTER BED 0 E'Distance to nearest: WAIT, Foundation Property Line i •r SEEPAGE PITS I i Depth Size Number " e- r r ''. 4 SIfIVIPS ❑"'DisMance'.to nearest: Well""-- *Fou'hdation- - Property-Cine - •- . . 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' 1 rules and re lations of the San Joaquin Local Health District. Home own r r 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 a on in such manner as to bec me subj t to workman's compensation taws of California."Contractor's hiring or sub-contracting signature certifies the oN wing: "I c fy at in the Orman of the work for which this permit is issued, i shall employ persons subject to workman's compensa- r tion laws of ifornia." The applican s cal or a ired in i ns. plate drawing on r or a side. Signed X Title: eA Date: 114, "= .E FOR DEPARTMENT USE ONLY Application Accepted by Date 2��T Area # Pit or Grout Inspection by Date Z7 gl Final Inspection by Date�Z_ } 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 CASH CK 9 RECEIVED BY DATE PERMI7•NO. 'SEH 13-24(REV,I/mo C U-2-141 Iry-Nei £H-14-26 �-r _ V