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APPLICATION FOR PERMIT a/I 665 9 �.SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ,jui J ^ ��9� Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'NVIMNMENTALHEAL" (Complete in Triplicate) DFir.na f C: r�11nrc Application is hereby made't`6YR8 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. `^ r •��J Job Addressbox tCJ .lel /1 ^City F. `/' ,�(ottSSize( P(�M Owner's Name rn rir t/a C D 6 Address /00= sl .FiagcJ caiowso/y\/Ca Phone 9 _O6 Contract Addres`s� X 19 Z, Licennsse No. (62373 Phone 66 6 TYPE OF WELL/PUMP: NEW WELL ❑ / WELL REPLACEMENT El DESTRUCTION El PUMP INSTALLATION M- SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of W�ILCasing 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Syecifications I'I Public 11 Other ❑ Delta Depth of Grout Seal /Type of Grout I I Irrigation —.Approx. Depth I I E) �j stern Surfac Seal Installed by _ Repair Work Done I�/Type of Pump �/S�" H.P. L-.. State Work Do� �.'(,�QJ 4 f, Well Destruction ❑ Well Diameter Sealing Material (top 509 I u tu+ ✓l�_d Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (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 a Character of soil to a depth of 3 feet: b P 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 I Depth Size Number SUMPS LI 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, staterules and regulations of the San Joaquin Local Health District. Home owner o nse ent'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 rson in suc manner as to ecome ject to workman's compensation laws of California."Contractor's hiring orsub-contracting signature certifies t following: "I reify that i nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion lawate: of Calif nia." A'dow Thee ap icant t f r all re rawmg one sidSigned Title: D OR DEPARTMENT USE ONLY Application Accepted by /C r t� Date b—Z/ Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY 0 -E q PERMIT'NO. 12-21 IREV.,, 3.20 "a/;q/ 0 O— b J