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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED &C �p (Complete in Triplicate) 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. 1 / 0 Job Address 7S h%5-f ✓///��46/&l �hwo �/ City IWC Lot Size PM Owner's Name �—&J,06tq-AielrfO (.Cb�,O ADd-dr�esl,,s JV177C� AS 4SLIVE Phone - 014 Contractor UAOOWAld �A�d/✓P�� Address �!/.P&41. ,41AI&,:- ,?BP.c: �.A Ucense No. Phone 0/D TYPE OF_WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O____ DESTRUCTION ❑ PUMP INSTALLATION ❑ SV�TEId REPAIRRRR�— 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 ® Wtluetrialw %lOPidE ❑ Open Bottom ❑ Manteca Dia.of Well Excavation Dia. of Well Casing ❑ Domestic/Private ® Gravel Pack 10 Tracy Type of Casing Pr'C Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation -Approx. Depth ❑ Eastern Surface Seal Installed by 1A 21 ff Repair Work Done ❑ Type of Pump H.P. State Wolk Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Q"y/ COM,?c Depth Filler Material (Below 50') Lf TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted H public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of fiving 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 ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,Mate 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: "1 certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Corrpplete drawing on reverse side. Signed )( W_d-w�4-4 k. /Ii.X Title: V' 4C� Date: FOR DEPARTMENT USE ONLY Application Accepted by C ��/"' _ -r Dote �� 2�( O J Anse Ph or Grout Inspection y Date �+ Final Inspection by Daft Additional Comments: J,Py&Wel, 7(�h'�0 'PiJCr1Di' A / rLZC' 'd /✓rfOCy ?/IIrTO/✓ ZA9- �/�1A' �321� ❑ Stk 466-6781 ❑ Lodi 389-3821 ❑ Manteca 823-7107 ❑ Tracy 835400 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA NMI FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT*NO, INFO CASH ♦ EN!}}4 rREV.1'e5