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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 486-6781 i 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, Job Address t/ff t►vt�'� City Shf-100N Lot Size PM Owner's Name � K`�L Cr rJ'o Address Q a L10q rlNUSAnIun,�i gy PhoneC S Y 3-2711 CA C-5;7 i i Contractor r-4,0M�w ar fiat. Address 00 C c Q License No.. y31139 J--Phan /S 61� ' TYP€ OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ j DISTANCE W NEAREST: SEPTIC TANK SEWER LINES 1-50 DISPOSAL FLD. PROP. LINE t :IM FOUNDATION a r AGRICULTURE WELL OTHER WELL--!Q--' PITS/SUMPS r= INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing 47I Ll Domestic/Private I /_Gravel Pack ❑ Tracy Type of Casing /OG1 C.[ry19et.. r�er� Specifications t l Public [1 Other F1 Delta Depth of Grout Seal r Type of Grout _ I I Irrigation V_Approx. De th I I Eastern�trti��t I,Surface Seal Installed by Repair Work Dane C7 Type of Pump r , Sul H.P. & State Work Done Well Destruction 171 Weil Diameter �� – Sealing Material (top 501 Ger,4,L f1)w& 4– 0 Q'11Viz�t"*'^}"f 2ift�ncjy6hDe th 57 Filler Material /Below 501 I. p TYPE OF SEPTIC WORK: NEW INSTALLATION I'I REPAIR/ADDITION LI DESTRUCTION i I (No septic system permitted if public sewer is I�. available within 200 feeLl Installation will serve: Residence— Commercial— Other "II Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 1� ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE, ❑ No. & Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITSI I Depth Size Number SUMPS LlDistance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ 1 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 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 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:" dr`jam 'hCSCE �1 1 ��ty�� The applicant must call for all required ins coons. Complete drawing on re /erse side. i Signed X I Title: - 77r�� vu�v'i!'S� Date: )-do FOR DEPARTMENT USE ONLY JL Application Accepted ybyy D Area Pit or Grout Inspection by Date ti Final Inspection by Date Additional Comments ❑ Stk 466-6781 I� ❑ 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 FEEII� ' INFO I AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. i t EH 13-21(REV.r i a 51 � EH 14-2t1 14