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�.. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Gam_ �� 1601 E. HAZELTON AVE., STOCKTON, CA p_ Telephone (209) 466-6781 �,c + PERMIT EXPIRES 1 YEAR FROM DATE ISSUED lei (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 Ryles and Regulations of the San Joaquin Local Health District. ,,// `' -/ Job Address _ �< 1 4 /yG Al[D Al �/ city ST 0 Lotea X�_ PM Owner's NameE<9 K✓�M t7.'(C Address �_Q6_lcl�'� S A -r /t C T) 'SA Phoneb 1 a CALtr Contractor e',-T-/ `ieo ,zg /�6 /Z0 7�' [.voo ID f3�lp6C Address License No.3Z) SSS Phoma 33Y-qhs TYPE OF WELL/PUMP: NEW WELLWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONX SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l ✓ F�� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ri ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Zr? Dia. of Well Casing C RDomestic/Private 6d Gravel Pack ❑ Tracy Type of Casing -r. � .6 pecifications El Public EI Other ❑ Delta Depth of Grout Seal Type of Grout 9 ❑ Irrigation ZZp__Approx. Depth ❑ Eastern Surface Seal Installed by innAl T Repair Work Done ❑ Type of Pump H.P. I 'f! - State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') 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 y 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 ❑ 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 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 must call lll for all required inspections. Complete drawing on reverse side. Signed X /tm / ._1_414.ol Title: 06-1— Date: FOR DEPARTMENT USE ONLY ` f� _ /� �7 Application Accepted by Date/ _ V V Area Pit o-Grout Inspection by ate 0 Final Inspection by Date ditional Comments: if Stk 466-6781 ❑ Lodi 369-3521 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r A licant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201' IFEE NFO AMOUN DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. s EH 1124 IRM I18 I1V ,11'� 'O-,(p-gs �rrr- IZv� ru t4-25 ... _ - - -_ _- _ - - _. 1" V