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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 herei1.n described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District.' ' PM S, Lot Size b' S^�-7 27 7 t Job Address .. , Owner's Name �5f-n�d - - Adelfess Contractor �tr��r Addressc �i,[L�+-"K-S� License No. Z .7 ., Phone __ TYPE OF WELL/PUMP: NEW WELL Ll WELL REPLACEMENT ❑ DESTRUCTION 0 j PUMP INSTALLATION ❑ SYSTEM REPAIR -7 OTHER C t DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES — DISPOSAL FLD, _. PROP. LINE —_ - 1 FOUNDATION AGRICULTURE WELL _ OTHER WELL ' -'PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_." l C Industrial // G Open Bottom G Manteca Dia. of Well Excavation Di _ a T of Well Casing r Specifications ❑ Domestic/Private r ❑ Gravel Pack Tracy Type of Casing { ❑ Public t p Other'l 4 ❑ Delta Depth of Grout Seal " ' Type of Groutl E C Irrigation --Approx.-Depth C Eastern Surface Seal Installed by-- I - - Repair Work Done ❑ Type of-P1.ump 3'` H.P. State Work Done Well Destruction ❑J,Well Diameter Sealing Material itbp 56'}" 1 Depth + t Filler Material (Below 501 t v TYPE OF SEPTIC WORK: NEW INSTALLATION J REPAIR/ADDITION DESTRUCTION C7 (No septic system permitted if public sewer is _ r ,r available within 200 feet.) Installation will serve': Residence_ Commercial-y- Other - A Number of living units: Number of,bedrooms Character of soil to a depth of%3 feet:__��_ Water table depth SEPTIC TANK 1. Type/Mfg � Capacity_-.- No. Compartments....... PKG. TREATMENT4PLT.❑S �� Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C No. &Length of lines', , Total length/size I FILTER BED _ Distance to,nearest: �Weli Foundation — Property Line Z Number, SEEPAGE PITS Depth 7 - Size -- I SUMPS L Dislant;to nearest:v , Wall +�Fdundation -- Property Line DISPOSAL PONDS ._ I hereby certify that I have prepared this.application and`thevtlie work wifl be done in accordance with San Joaquin county ordinances,state laws, and I rules and regulations of the San Joaquin Local Health District, i i fr which this Home owner or licensed agent's sighature certifies the following: "I cer�rfy.:that in the performance of the workopermit ie issued, 1 shell not- J employ any person in such manner as to become subject to workman's compensation taws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the pdrformence of the work for which this permit is issudd,-Lshell employ persons subiect,to workman's compensa- tion laws of California." The applicant must call for a uired inspectio C lete drawing on_.reverse side. Signed Title: -� rf _ Pate: CDEPARTMENT USE ONLY Application Accepted by 4�A-28, Date Mo f Area�1 — Pit or Grout Inspection bb� Date _ F-nal I tion by r. w Additional Comments: ❑ Stk 466-6781 G Lodi 3693627 Manteca 823-7104 ❑ Tracy 8354NM Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY ;ATE PERMIT'N0. INFO + EM 13-24(REV.,�e5) to A EH 14-26 i