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APPLICATION.FOR PERMIT Y f SAN JOAQ U N.LOCAL HEALTH DISTRICT a 1601 E. HAZE T ON AVE.,.STOCKTON CA NDwfa ow.XA, 2 Telephone (209) 466-6781 {� H , . PERMIT EXPIRES'1 YEAR'FROM DATE ISSUED c �? t �Pfl Inrh i S •, ', �.,_ •: ;7'e ;�� . (Complete in Triplicate) A� ., � � .,. /� Application is heieby 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. {� _ �'I.7 � f I • � . �r,n.' , S � .. i Job Address G�l!v `` �N - City Lot Size �+� PM t Owner's Name CdA. "t��0% Address aIO S-A A16 IJV17 � Phone 7� T �v�• r., Wit.•- i C f �i -�.w+nPR„t.+�$•�r"F^-.sR ' •o.IIi+ �.�w.w..:r.+-++w+�...-y.....-..: r.,.,� �aur=r.-r” T Contractor .J C L Address ~^ License No. Phone �~ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , _D,ISPOSAL FLD- PROP. 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 of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. 1 : State Work Done_ Well Destruction ❑ Well Diameter Sealing'Material (top 50'i Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIO DESTRUCTION ❑ [No septic system permitted if public sewer is available within 200 feet.] 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 i Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest:- i Wel!"--�--Foundation Property Line LEACHING LINE ❑ No. & Length'of lines Total length/size d FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS ❑ Depth ? Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ E I hereby certify that I have prepared this application and tFiat 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. 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, I shall not j employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature m 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 Califo`r'nia." The ap • ant /Ifit call fo requir ct0h Complete drawing on reverse side. Signed X ! Title: Date: F DEPARTMENT USE ONLY Application Accepted by _ , " a,�. '� . Q• �ti Date —T7 Area Pit or Grout Inspection by Date Final Ins action by / /Date Additional Comments: U (Gl (,� CfJ(,lC� 7 �' �U ❑ Stk 466-6781 ❑ Lodi 69-3621 ❑ Manteca a23-7104 ❑ Tracy 635-6385 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 CK RECEIVED BY DATE PERMIT'NO. INFO CASH O + EH 13.24 1REY,t/x 57 /-S EH 14-26 /�W 4 _ I