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r APPLICATION FOR PERMIT �p SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA J/ 7� cy Telephone (2091 466-6781 7 y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is Releby made to the San J-,qt Local eH althy_`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. / Y1 ,1 Job Addrass /2 63o XMk1',NS oN wCitty�`r0 D r Lot Size_ /0 ^C PM _ Owner's Name 40-0 4 R(A:T n 1{ Address S Lr�//.C3 — *2 1 0 Phone Contractor et iW teleOS V Address A hoe 178 License Ng32D rS Phone —V2 ' TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION-*119 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 60 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIQNW ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing vS ' � r omestic/Private -K Gravel Pack ❑ Tracy Type of Casing `G Specifications d M Public ❑ Other ❑ Delta Depth of Grout Seal 16 4D Type of Grout_44rC_A Wrrigation 3 a2 Approx. Depth � II Eastern Surface Seal Installed byS6,11-f Q _ Repair Work Done EJ Type of Pump -.2�+6 H.P. Z 1 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 1 rt)Installation will serve: Residence_ Commercial_ Other available within 200 feet.) 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 ❑ Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Dibtrict. Home owner or licensed agent's signature cenifies 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." The applicant must call to all quired inspections. Complete drawing on reverse side. Signed K_ Title:_CmAIMJ.r Date: Z ' FOR DEPARTMENT USE ONLY Application Accepted by Date~-' `Z--LJ Area Pit or Grout Inspection by � Datar?,"a`� Final Inspection by LiI � Date ' Additional Comments: ❑ Stk 486-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 Applicant- Return all copies to: Envirohmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT ODE MOUNT REMITTED OK RECEIVED BY DATE PERMIT'NO. NFO EH;324(REV.1,.5, EH 14-29 Ica fis ' ��