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` APPLICATION FOR PERMIT i! �« S1 JOAQUIN LOCAL HEALTH DISTRICT +r ' ' + 1 E. HAZELTON AVE., STOCKTON, CA Telephone {2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) �p 1 I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work harem 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. Job Address 1w-3 �!& # -� %Z City�Q?7 I Lot Size PM OA"A1 4e,A Ij I Owner's Name �r s O� AYrX��O y��/d�/Address ��..�2 Xie 3�7.Y - !�Phone I� M Contractor + Address /� License No.WO Z6^Phone TYPE OF WELL/PUMP: NEW WELL &K WELL REPLACEMENT ❑R DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ,OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F;LD. PROP. LINE C FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ 0 n Bottom ❑ Manteca Dia. of Well Excavation .f F Dia.of Well Casing ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing it, Specifications � ❑ Public ❑ Other Delta Depth of Grout Seal II l Type of Grout 4! Q ❑ Irrigation __.Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 at 111 Depth _ Filler Material (Below 501 ! � 'i. TYPE OF SE IC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION',❑ (No'septic system permitted if public sewer is II available within 200 feet.) I' Installation will serve: Residence_ Commercial^,,,,_ Other 7 I Number of living units: Number of bedrooms !a Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ jj Method of Disposal Distance to nearest: Well Foundation I; Property Line ;f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number J �! SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f j 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 i. rules and regulations of the San Joaquin Local Health District. l} j Home owner or licensed agent's signature certifies the following: "I certify that in the performance of theilwork 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 I certifies the following:"I certify that in the performanc of the work for which this permit is issued;;I shall mpioy persons subject to workman's compensa- tion laws of California." I t The applicant must call for all r aired ' spactio s. Complete drawing on reverse side. Signed Title: i-r-11ZDate: •OP W7 -ARTMENT USE ONLY �1 a.� X / Application A tby _ Area ej I1 t Pit or Grout Inspection by Date j� Final Inspection b' Date V j Additional Comments: co 0 ❑ Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 823W104 ❑ Tracy 83j-63E5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Booi12009, Stk., CA 95201.FEE _ INFO AMOUNT DUEf AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. a EH 1bM[REV.ties/ 3 - �j J - �y70Z F- EM14-25 v J