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`. �% APPNCATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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 compliancewith San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. T Job Address �.L .0 � F /3'Z 4( (-ernonT Sr City l CACTO Lot Size I tZ0 � � PM Owner's Naame(_ I"y��-j U 5� Address a Afa1JnA3C\ �ct7Jc��VY-�..Tt 200 Phon S Ff3 Ste-( ContractdZZh..f?.0 TcI TrJ-a�wtOuX+A `'4 ddress 0 _1 .v d 11Au A L.O•�tcr� icense No. 434343 Phon IS (o�it 238-7 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 „\ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS V , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1.S .r.c.y Dia. of Well Casing ❑ Domestic/Private $Gravel Pack ❑ Tracy Type of Casing WC. Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal D.O FC Type ype of Grout mC✓•T ❑ Irrigation &OApprox. Depth ❑ Eastern Surface Seal Installed Repair Work Done ❑ Type of Pump H.P. State Work Done `� n Well Destruction ❑ Well Diameter Sealing Material (top 501 MOv1Tox.«J 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.) 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 ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ 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." The applic ust call for 0 r I Inspections. Complete drawing on reverse side. Signed Title: G OL D615- Date: 3 D ONLY Application Accepted b lop Date 3�� —�7ZArea L� /W Ih p Pitr Grout I a ti y D to�'��jyZ coon by 4 C1 Dat. �v-! I— Addi[icnal Comments: Q:�Sk 488-8781 ❑ L& 36 21 ❑ Manteca 823-7104 ❑ Tracy 8358385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952111 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. '. INFO CASH �S vri r '° EH tb24 1flEy.1/s 51 3� EH 1428