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0 APPLICATION FOR PERMIT 16 " 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) QC 2. 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 Ryles and Regulations of the San Joaquin Local Health District. BlQ Job Address �S wes-✓' ✓ALn!i P/ ob City ��'>/ Lot Size PM Owner's Name (960k'6rA PAC%y�C 69A QAdd. J�Am4�4Y 10M/P Phone 91L 2i.r/ Contractor 1,?JWA( j e/Jl4h4WLf11 Address BOX 6�7/jh�n�i✓urC7.PeA,tr C41V License No. Phone AIL93 TYPE OF WELL/PUMP: NEW WELL ;9 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 ❑.wdeser al mai!to Pi / WGN.Bd El Bottom ❑ Manteca Dia. of Well Excavation Y Dia. of Well Casing ❑ Domestic/Private A Gravel Pack 9 Tracy Type of Casing PYL/ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ElIrrigation -41Approx. Depth El Eastern Surface Seal Installed by /t d 0_/1V ae9 r /1SSOC Repair Work Done ❑ Type of Pump leper H.P. State Work Done - Well Destruction ❑ Well Diameter ?-�r Sealing Material (top 501 1fE1V13A0f71 0- /7 Depth_ Filler Material (Below 501 it�r S4,4 /7- 1107 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 Capacity No. 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 ❑ 1 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." Contractors 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 applica�n-tTQ/J/{�t call for all required piinnspections. Complete drawing on reverse side. Signed Y Y'^,0'"`ZL'o /y VvFJGC Title: lh"A^ Date: &AS 4 FOR DEPARTMENT USE ONLY Application Accepted by -C �✓o'i� Date Area �7 / Ort. Pit or Grout Inspection Ky` Date✓ Final Inspection by Date Additional Comments: �R71G.✓b' � CONT,t/�ct'/OQ' /.16"MgJ1_-P d 14SS C , A146.t-M 1W 2a9 -94�- ❑ Stk 466-6781 ❑ Lodi 3643621 ❑ 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 CK RECEIVED BY DATE PERMIYNO. INFO CASH + EH 13-24 IREV.1/e 51 EH 1428