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• APPLICATION FOR PERMIT SAN JOAQUIN L0. L'HEALTH DISTRICT s.r, 1601 E. WELTON AVE., STOCKTON, CA Telephohe (209) 466-6791 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED" (Complete in Triplicate) 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. �� :",1 Job Address 1G ?y �,qsr'.,ALpiNf% /'7VL�t1i2 ' Ci STGLAr7VJ . r., . tY.. LotSiie . /2. 6 /4G.. PM Owner's Name 12fi91e1V6 y- IC PF - Address 14.:211 e 44r e44 a v6 Phone ya —& Contractor -51a 7771•^NiNFn'T Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ SO/C .QOQ/41�75 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 6d MO../Tafr LUELLS DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom i ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Peck ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ! ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation - 4prcut. Depth 1 ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter - Sealing Material (top 501 Depth Fillet Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i available within 200 feet.) Installation will some: Residence_ Commercial— Other ' .) Number of living units:_ Number of bedrooms I+ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines ! Total langth/size FILTER BED ❑ Distance to nearest: Well Foundation property Line SEEPAGE PITS j ❑ Depth _ Size LNdmbdtSUMPS ❑ Distance to nearest: Well Foundationperty Line DISPOSAL PONDS ❑ ? I hereby certify that I have prepared this applicatlon and that the Work will be done in accordance with San Joaquid county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I Home owner or licensed agent's signature bartified the folloWingi "I ceftify that in the performance of the work for which this permit is issued, I shalt not employ any person in such mbnner as to become subject to Workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the following:"I certify that in the peHormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Celrforhis. !. The applicant must call for all required inspections. Complefe drawing on reverse side. Sighed �T ` title: f 20J1r1' l�Ya/IOG�1l1G/S�Dete: 2—/5�9 O N►4QGls i f4SSaCi�FT� �C FO PA USE ONLY , Application Accepted by lie OL - -- i Date 2— Z L/ Area �5 3 Ph or Grout Inspection by ` Date Fihal Inspection by bate Additional Comments: FFkr1! -(-Ct err 20un.Y14a 6cc>4-cc �/L ,j iNr;�.�P� /�� jy/ � , ❑ Stk 466-6781 ' d Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6985 Applicant- Return all copies to: Environmental Health Permit/Services 150) E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVEtl BYRDATI PERMIT NO. + EH 3-24(REV.V a 6) EH 1429 Q Q 0 O-II