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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA t. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` ^ 3S� �^ ,� mplete in Triplicate) Application is here y made to the San Jo In Local ealth 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. X4NF1_:4aL' /Vc ��'3iq-0 /JCk c j- HAfLy&Sr Cit P--LPLN Lot Size PM r r r 1. Job Address Y 1WW 25-9-0Z-03 AMOUNT REMITTED L715 -y R5 GdX �J'^�Phone Owner's Name�Lk- kq Address % m/a-vrir-Ley f -+fir 2A745� Jgt STLicense No..:T ZZF0 Phone 9Y$43 Contractor 41&ress 1� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER P. d 7re5r go,2a,..5 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _hDI TD GSr FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _j6"10/19 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �nytJ/Z 7D 61 ��C��esing ❑ Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation Dia. of''��e`l''I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications9V1rXF-1L(e I"1 Public ❑ Other fl Delta Depth of Grout Seal Type of Grout AY --.L I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ ✓t6-47L'A// Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION I I ;No septic system permitted it 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 I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I rN I hereby certify that 1 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: "1 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant ust call for 11 required inspections. Complete drawing on reverse side. Signed X Si+r`F p Title: G%-0L-6�1 Srr Date: 67-7 --qO FOEPARTMENT USE ONLY Application Accepted by � Date C Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3693621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t. Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f EN 1324 IREV. 1/. m EN t425 FEE NFO AMOUNT DUE AMOUNT REMITTED CtX-SH RECEIVED aY DATE PERMIT NO. 'zS I-II - /IHi90 19c-lilil_v-,