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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 (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 JJ / �Y1e (rj .�Cr ' City 1r) Lot Size �_ PM Owner's Name42Y Si-�"ki(Y Address ,/ A 1 /- 1�� V/JI / - 'J✓� �'r Phone 7 7 ' - "Contractor's Name -' License No. t 5 7 Z Phone -339- 113o TYPE OF�WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ -PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ �y� DISTANCE TO NEAREST: SEPTIC-TANK SEWER LINES -DISPOSAL FI-D.1-25- PROP.lINE_�w, ' ' FOUNDATION �,�'AGRICULTURE WELL .i OTHER WELL �" _ ''''''pppppp PIT /SUMPS INTENDED USE TYPE-OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS,- ph ❑ Industrial ' - +-1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �S/O �O Domestic/Prlvate '❑ Gravel Pack' ❑ Tracy Type of CasingS+f-P-o ❑ Public' ' Specifications 1 Ckj e% c�, ❑ Other '°,G Delta Depth of Grout Seal _ �D ❑ Irri stion '�'` Type of Grout 9 _.Approx. Depth -p--Eaetem.,'�, Surface Seal Installed by�l.zrol' Repair Work Done , ❑ Type of Pump H,p �. State Work Done + Well Destruction ❑ Well Diameter .Sealing Material (top (r�srr pu9� Depth S N. Filler Material = ow 50') ( �" TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public-Sewer ' 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 Tojal'length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS ❑ Depth Number SUMPS ❑ Distance to nearest: Well Foundation Property Line - ... _ _ DISPOSAL PONDS ❑ ' 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquincountyordinances,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 l employ any person in such manner-as to become subject to workman's oompalisation laws of California.. Contracf wit hiring or sub-contracting issued, signature certifies the fopowing:"I certify that In the performance of the work for which this permit is issued;1 shall employ persons ring-or to workmen's campansa- ', Non laws of California." sub �.. The applicant in c 1 for all required i]epectlons. Complete drawing on reverse side. Signed !"� Title: Date: tFOR DEPARTMENT USE ONLY �]py Application Accepted by �,,,'{1`� c�1 Data_�- C9_1 Area i ' Pit or Grout Inspection Date `Final Inspection by Date Additional Comments:' ' ❑ Stk 466-6781 I ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8358386 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 = ' t . ! FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BV - INIO H DATE PERMRNO. ,ER 13-24(REV.1a/WI ��-- X^�—'�t_� 1- EH 1416 (/ /y/)• 1 " !/ - U '�