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APPLICATION 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 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. Job Address / 1Tt pr ill0i /Zp City GQ1-7Z Lot Size PM oiL co, i°o �dx S�c�es� � CPrw 77a-3y Owner's Name o Address Phone a ContragWil Name X"7" f?00?2 T License No. 206 Phone61-26/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCr NEARES�SEPTIC TANK - SEWER LINES - - DISPOSAL F1111. LINE FOUNDATION AGRICULTURE WELL OTHER WEL fS UMPS INTENDED USE T)ril WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open'Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack - ❑ Tracy` Type of Casing Specifications r ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type lof Grout ❑ Irrigation _t ___4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done,," Well Destructia� ❑ Well Diameter Sealing Material (top 501 0 \ Depth Filler Material (Below 501 1 TYPE OF SEPTIC WORK: -NEW TSTALLA\N ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted 'rf publ'w r is i available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of Irving units: _ Number of bedrooms Character of soil to a depth of 3,lest: Water table depth SEPTIC TANK ❑ TypOmfg CapacityNo. Compartments PKG. TREATMENT PLT.❑ \' ' Method of Disposal Distance to nearest: \Well Foundation Property Line q LEACHING LINE e No. Length of lines Z-�t "" AW li 90 Total length/size d� i FILTER BED ❑ Dista ce to nearest: wait,, : Foundation 7 0 Property Line SEEPAGE PITS - 1-_Dptl� 2 Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ p ` I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqui untyordinances, state laws, and rules and regulations of the San Joaquin Local Health District. + Home owner or licensed agent's signature certifies the following:11 ce�,tify ttlat 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 workmahrilikompolmation laws of California."Contractor's hiring or sub-contracting signature certifies the toNowing: ''-1 1h�L jn the perfgrranoe-of�he�verk fiorch tugs permit is issuedt.l lett to workman's compansa- tion laws of Cafrfornia." '<.a r.q """111111 The applieant must all mqu' ,din s. Complete drawing on ide. I - Signed Title: u Da FOR DEPARTM T SE'IONLY Application Accepted by -DateArea- - Area Pit r Grout Inspection by Date ' Final Inspection b Date Additional Comments: ❑ Stk 4668781 ❑ Lodi 3621 Mantels 7104 ❑ tracy 8358385 — AAZr! A i f'LJ.eGaY, Applicant -Return.all copies to:Environmental Health-Permit/Services 1601-E. Hal Ave:;-P.O:-Box 2009,Stk.,0�t------/LL..____._ INFO AMOUNT DUE AMOUNT REMITTED GBH REGEIVED'By'• DATE PERMIT'NO. +EH 1a24 Il roi®r � - I C ), > - 5zcz _4Go