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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 E. HAZEL T ON AVE., STOCKTON, CA Telephone (2091466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED Ej�`UT ` t-'A'' HEALTH F ERiii l/SEiiVIC1rS (Complete in Triplicate) Application is hereby made to the San Joaquin Local Hesm 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. I O,it Moors Job Address 2-TOO yeAw City 144 Lot Size Pro**,y Alp PM Owner's Name U I q Ikvm 4Il Address Iii 4,q �l Phone Z •S Sp t� OF Address ¢I ifW/fA ---License No. �� Phate�l 2'Ssq TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK NA __ SEWER LINES NA DISPOSAL FLD.. N_ PROP. LINE FOUNDATION NA- — AGRICULTURE WELL#A--- OTHER WELL PITS/SUMPS t INTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS # [7 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation if itDia.of Wei Casing / /Private )' Gravel Pack ❑ Tracy Type of Casing Specifications ('I Public n other El Delta Depth of Grout Seal x u �---- Type of Grout 9d"Lo wy I I Irrigation _—.Approx. Depth I I Eastern Surface Seal Installed by YY -- Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction F] Well Diameter Sealing Material (top 50') Depth Filer Material 18e1aw WI E OF SEPTIC WORK: NEW INSTALLATION 1 i REPAIR/ADDITION l ! DESTRUCTION I I INoavailable septic system permitted if public sewer i available within 200 feet-I Installation Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 ater table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Wall ation Property Line LEACHING LINE Ll No. 8 Length es hlsize FILTER BED G3 Drst to nearest: Well Foundation Pr SEEPAGE PITS I I Depth Size __ _ Number SUMPS i I Distance to nearest: Wei. Foundation___ Property Line AL PONDS n I hereby certify that 1 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. Hone 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 shelf not employ any peen in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-coMnctinp signature certifies the following:"I certify that in the paAormance of the work for which this permit is issued.I shall employ pesos subject to workman's compensa- tion laws of California." Thea t tions. Plate jp4sverse side, signed rale: Martha- wl� G�S>< _ ,pate: forst S l9ty Ar FOR DEPARTMENT USE ONLY Application Accepted by Z;� Date L7 rea Pit or Grout Inspection by Date 1 ' f Final Inspection by Dow �d Additional Comments: ❑ Stk 4668781 ❑ Lodi 389-3621 ❑ Manteca 823-7104 ❑ Tracy am-=5 Applicant . Return all copies to: Environments!Health Permit/Services 1601 E. Hazelton Ave., i.O. Bots 2008, Sfk.. CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMR'No. INFO ` EN/124 etEV.t/a 5) t'Q �t EH 14-zs