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l!•v� �c - vu APPLICATION FOR PERMIT USAN JOAQUIN LOCAL HEALTH DISTF1srlir 1601 E. HAZELTON 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 tot a permit to construct and/or install the workherein described. Tibia 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. ' b 2Wo N\ ( {-f-W Job Address/W .4 }{Y Qg 213e"htAgd I � 0 (City Ly D� Lot Size Li 4C'g ir S PM Owner's Name Or 1J/M q AddressC S'AAft r Phone ` ,I 51� 7 Contractor A10 Y,q.11E DA Address 76 DO L K��Jf��h l}I✓ LA! License No.G1�TJ��`'f Phone Y�� 301 TYPE OF WELL/PUMP: NEW WELL A WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLPITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom -❑ Manteca Dia. of Well Excavation ~ Dia. of Well Casing S El Domestic/Private ((Gravel Pack ❑ Tracy Type of Casing A tid - Specifications -f, (1 Public )❑ Other ❑ Delta Depth of,Grout Seal Slb-106 Type of Grout A1tQ1 6,� N / . I I Irrigation �Approx. Depth I I Eastern Surface Seal Installed by c;AV90CA/_ _ Repair Work Done ❑ Type of Pump H.P. State Work Done �Well�Destruction ❑ �Well Diameter Seating Material Itop 501 c�1 ('/IT C 110✓W+Wiepth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 7 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.I 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.Cl Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE - ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di3trict. 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, 1 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 applica must call forall required insp c i ns. Complete drawing on arse side. q � 7- 8 Signed / Title: Date: --�'" FOR DEPARTMENT USE ONLY Application A,cepted by '�f/ Date ` Y Area Pit or Grout Inspection Date ' _16_9 O Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE �+ PERMITNO. EN 1420