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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 Heafth 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. 7 t� q C/ �jQ 4-A� 9�37� Q�Pr,— Job Job Address /G iN lel& gal M4C 141-'1I4y P, City C Lot Size PQM/ Owner's Name A• 7m/w h r!f;:�O Address shone } p� p g/4 Contractor oL rl t ( Address 3/2A a � A ey1 n aWp Fc License No.1ats3o Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER XMb fill(T-0 C W LL-s DISTANCE TO NEAREST: SEPTIC TANK E3O0 ±SEWER LINES d6,00,,I t1� DISPOSAL FLD. PROP. LINE t f FOUNDATION [Q r AGRICULTURE WELD OTHER WELL-3400' 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 Gravel Pack ")9 Tracy Type of Casing .Z ��- Specifications ❑ Public ❑ Other O Delta Depth of Grout Seal r n1 ih Type of Grout 52 en? ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by L Repair Work Done ❑ Type of Pump _AAnn_& H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permi pu is sewer is available within 20 .1 Installation wi e: Residence_ Commercial_ Other Number of living units. Number of bedrooms Character of soil to a depth o t: Water table depth SEPTIC TANK ❑ Type/Mfg Capac' No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: We Foundation ::: Property Line LEACHING LINE ❑ No. & Length Total length/size FILTER BED ❑ Dista o nearest: Well Foundation Property Line SEEP�PITS ❑ Depth Size Number SUM ❑ Distance to nearest: Well Foundation Property Line OSALPONDS ❑ 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,I shall employ persons subject to workman's compensa- tion laws of alifornia." The applicant m t call for all eq fired in pections. Complete drawing on reverse side. } Signed I Title: �1ri1llj I ` Date: c FOR DEPARTMENT USE ONLY Application Accepted by - Date kX47 Area Pit or Grout Inspectionby / ' ate 4�-oo Final Inspection by I v/ � A Q Date _j_ Additional Comments: J 'OIC[ 1^. 15`S c!tee e"M D r !ja i 'bz;/ y n1 4e, 'f / rczex * d Old V+ ❑ Stk 466-6781 ❑ Lodi 369 1 C) Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 INFO AMOUNT DUE AMOUNT REMITTED I H RECEIVED BY DATE PERMIT'N0. + EH 14-24(REV.r/a s) EH 14.26 1p