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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 E. HAZETON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1 r 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 Co6nty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. II Job Address yD60 G✓iQGNEr? f��ErGHTS �o4U City S'TOc,rrOA/ Lot Size ^' 7l0sna u Owner's Name 44Snl7' -T05C [Td'C'4 r Address `✓000 A144 i5Z AfEre.hIr5 IVDA Phone 609/ 9c;&-3vao SQcc}rvr� c�M A`1-rrz.&pis r1 rFt S+veldt,n rSzps y65-y7 Z Contractor kZCrV1Cr6DJER Address 9795 $uStiv s5 �,q� D v�License No.51 Z� PT1one<9/�3 G i7a/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ R ` PUMP INSTALLATION ❑ SYSTEM REPAIR EIOTHER)K Sart. P?56RL0vG5 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES NA DISPOSAL FLD. /VA- PROP, LINE Nh FOUNDATION :!L '_7/Q' AGRICULTURE WELL NA OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Cl Gravel Pack .❑ Tracy Type of Casing Specifications f i Public Cl Other n Delta Depth of Grout Seal Type of Grout € I Irrigation —,Approx. Depth I I Eastern Surface Seal Installed by r - Repair Work Done ❑ Type of Pump H,P. State Work pone Well Destruction ❑ Well Diameter. Sealing Material ftop 50'1 Depth Filler Material (Below 50') Q TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 'REPAIR/ADDITION I i DESTRUCTION t I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_� Commercial_ nOther,~ Number of living units: Number of bedrooms,- Character edrooms Character of soil to a depth of 3 feet:11 Water table depth SEPTIC TANK ❑ Type/Mfg), Capacity No. Compartments PKG. TREATMENT PLT. El {� r Method of Disposal Distance to'nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Len�th of lines -��~ 9 Total length/size FILTER BED ❑ Distance tpi nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Number Vi SUMPS C Distance to nearest: Well YrFoundation Property Line- DISPOSAL PONDS ❑ 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. 4 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: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applica st call for all required inspections. Complete drawing on reverse side. Signed X — .1• Title: w —cDate: 19 41 R DEPARTMENT USE ONLY Application Accepted by Date �Z Area Pit or Grout Inspection by Date Final Inspection b Date Additional Comments: 4 ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104' ❑ Tracy 835-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK 9 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EH 13-24 IREV. �?/ --/1 i EH 74-26I U3ZDy i