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41 Ca fry d,-ono I��f�va� APPLICATION FOR PERMIT �� yf--L�,. �... Iv--f e SAN JOAQUIN LOCAL WEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j r�'✓G N-�'� / (Complete in.Triplicate) Zc 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 N9.545 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. i�� ltf: 01 ? /S � Lot Size 020�l 69 PM Job Address � City Owner's Name ,L)C-09 Address _L`p l-� Phone a°�J •[7� r Q Contractor's Name �Zb ense No. &Q Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTiON ❑ PUMP INSTALLATION SYSTEM REPAIR 11 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK U/� r� SEWER LINES L DISPOSAL FLD.&Lt PROP. LINE —O-D FOUNDATION — AGRICULTURE WELL VGL26-7 OTHER WELL 06 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom LJ Manteca Dia. of Well Excavation - Dia. of Well Casing Domestic/Private Gravel Pack El Tracy Type of Casing Specifications i� ❑ Public C1 Other © Delta Depth of Grout Seal _ Type of Grout ❑ Irrigation --Approx. De th ❑ Eastern Surf ce Seal Installed by Repair Work Done C1 Type of Pump _ H.P._—/ ,DeState Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') «.Depth- —Filler-Material-(Below-50.) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system i f permitted if public sewer is o Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: _—Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 3 e LEACHING LINE C1 No. length/size No. & Length of pines � , I FILTER BED "`❑•'Distance-to nebr st: -Well""" ""�"�Fpundatior}' • Property Line SEEPAGE PITS ❑ Depth Size _ T Number SUMPS ❑ Distance to nearest: Well t Foundation Property Line DISPOSAL PONDS ❑ - hat the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and t rules and regulations of the San Joaquin Local Health District. 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, t 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." The applicant st call for all required inspe ions. Complete rawinglon reverse side. Signed x Title: _ r Date: E R DEPARTMENT USE ONLY s C�7/ Date Area Application Accepted by t Pit or Grout Inspection by Date inal Inspection by Date Additional Comments: .2? r� res rvY- ,�/tl~ ro+� ' f-I�'k'�� h ,�45!1= ❑ Stk 466-fi781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 55201 ti i z - ---FEET AMOUNT DUE ' -" AMOUNN-REMITTED— ' '�RECEIVED BY -'DATE �PERMI}NQS. INFO �- etc 1417 ` j i + EH 13-20[REV.10/831 1 '� 5• O'O `5 �-- -- ,I ci/v-%. �v�r=^1R q, .. EH 1426