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✓ APPLICATION FOR PERMIT �•.� N JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA • b� Telephone (209) 466-6781 ® n PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applicati eieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is mad ' mpliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Loca ealth District. Job Address Co" 0 C--HA-Z ' _� WAY City "V Lot Size 1qO t X, 1$0 r PM Owner's Name SI'1j1 L Ort (�,;,-"1�Awy Address 11390, WILL OL % ��S RO. S�9 Phone 46 ��'-7 w&s'; 14 X1-7-M i D2 t i L r-'v6 b k>. k i-V—c f i �qaW.,q 7 y a. Contractor'DIE L_L r IVy 12c�/t�. Address 3�"�U UA_A to 1>Z _ License No. 980(0,1 Phone!l� G3C3 Z .7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE Llttwc rUp FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS —G57_5 7y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /01' Dia. of Well Casing 44 Domestic/Private L- Gravel Pack ❑ Tracy Type of Casing PA_ Specifications 1"1 Public Other F1 Delta Depth of Grout Seal 3 Type ofGrout _ I I Irrigation �� Approx. Depth I I Eastern Surface Seal Installed byCOAX'TA-� 5�� V1�tr 13Oa( Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter y�r Sealing Material (top 501 � M6-V- ''"- &-/ Depth 1/0 Filler Material (Below 501 _s '> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (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 Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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: "1 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." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X_ /C -t"'� Title: 6 -DIC4i S; Date: FOR PAR USE ONLY JJ Application Accepted by Date /o2-1/ Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 O Lodi 369-3621 O 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 FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. EH 17.241REV.rinst O EH 1424 -