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N,,, 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 8 3 13914,1/4 re2-ml / City/S'<Ak"P0_ Lot Size � �>7/ PML P Owner's Nam((e7CA� IIA-2 AJ k/l✓ Address �j�.5 h ��/ le /�f/J "c/ Phone Zz " feo Contractor /{p6t R,Cc-- )-A7/bJ'✓ dress iGe�o.��6 �I�1 Phone OQ.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 r, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �y r ❑ industrial >IZpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing { A' Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing /-2- Specifications [IPublic ❑ Other ❑ Delta Depth of Grout Seal SO Type of Grout Pun Pa 1 ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by S�zl/�• �` 'Cd'� Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 �. 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 Hn e: Residence_ Commercial_ Other Number of liv'mg units: Number of bedrooms Character of soil to a depth of 3 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 ❑ 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 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 compemation laws of California." Contractors 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 compens i- tion laws of California." r The applicant gywt call for all required inspect' ns. ate drawing on reverse side. Signed �/� Title: �!_Sy�x Date: I-1 K?7 FOR DEPARTMENT USE ONLY L� A mcation Accepted by q Date // Area ®/ � - 1u31 Pit or Grout Inspection by Date e' _ Final Inspection by Date a Additional Comments: i� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354KM Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INr4 AMOUNT D''UllECK 0 AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO�./ ♦ EHIINIREV.1/est 7Q-OV I_'Y PT—7/ ` EM 1423