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APPLICATION FOR PERMIT it SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) BG 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 County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. //�� DQ /t Job Address 7Sr✓r tla,L Y/Lliq AOA/) City 194901 Lot Size PM Owner's Name F:160'aCGtA PAt1116 COJAP A✓✓ddrre��ss��I WCSI -V.,4LAILM r T 4Cl Phone a G Z! Contractor�iFa _W 9 C'4/ONC)/I Address&POy� V/.✓/� of if-",Ly License No. Phone 47f9 '9o�O TYPE OF WELL/PUMP: NEW WELL SK WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /hllRdus[rl8 .Pi.Jf1 C1 open Bottom El Manteca Dia. of Well Excavation 1 Dia. of Well Casing 13I oa Domestic/PrivateWtGravel Pack 5G Tracy Type of Casing P✓C Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 6 7•a Type of Grout 94d'cerf•rr ❑ Irrigation ZfApprox. Depth ❑ Eastern Surface Seal Installed by '40a"J¢aper P fi Repair Work Done ❑ Type of Pump f✓df✓£ H.P. State Work Done Well Destruction ❑ Well Diameter `Lff Sealing Material (top 501 aw-rear'/1E Depth Filler Material (Below 50') 7 3 rY/df/7"Cl f4,Yh TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 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 CapacityNo. Compartments PKG. TREATMENT PLT. ❑ 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 ❑ Depth Size Number SUMPS ❑ 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 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 California." The applicant rAust call for all r�eequiredtr iinlspec)ons. Complete drawing on reverse side.. Signed x (AILCO Title: 6+A1 "A, Date: z S g FOR DEPARTMENT USE ONLY Application Accepted by •C/vl�C� — i. Date 111271i5_ Area /7 Pit or Grout Inspection byp Date Final Inspection by Date Additional Comments: Q,Pf//7n/A 3U,8-c�aAH,P�rra� �l-� L11ERAtraC S —rWinil114 lav- 948-i?at, ❑ 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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'N0, INFO CASH \' ♦ EH 1344(RW.1/55) \ '(�7j2S EH W28 L�