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APPLICATION FOR PERMIT lv< SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA �'4+ Telephone (209) 466-6781 ~' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A (Complete in Triplicate) o Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described, This appy on made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Jo n Local Health District. Job Address Geo t l+V1-tW qY ( L–ODI city Lot Size PM 1 Owner's Name 00 Lt61-,+S c r c4, J Address ithp ( IWA AVE. C05-Th F'IF�4 Phone { Contractor i tro is Address r5 IgRN36L_p OR, 11ARTIIL�Zse No. Phone�41 u8 84bo TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES gl4l5OS -tLp- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL__X_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom L1 Manteca Dia. of Well Excavation _ Dia. of Well Casing, ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing `tPVC= Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 147-411 ❑ Irrigation ---Approx. Depth 11 Eastern Surface Seal Installed by EX P�96LT11W IDR 1L4 tAt 5EfZ tcF Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) x Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Watir 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 ❑ Distance to nearest: Well Foundation Property Line J SEEPAGE PITS LJ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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." i TheaPP q lican m t call for all re uir i s pact' . Complete drawing on reverse,side. Signedh Title: '�y r u .,.._. _ Date: q5 SE ONLY { Application Accepted b Date Area Pit or Grout Inspec i y ate,3�'-O Final Inspection Date Additional Comma s: Q Stk 466-6781 L' Lodi 369-3621 ❑ Man 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 H RECEIVED BY DATE PERMIT NO. , + EH t3-24 TREY-I i 8 51 EH 14-26 �_ C] s, '-i1.7