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r 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 (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 Rules and Regulations of the San Joaquin Local Health District. Job Address -7S/ I'VQ 5'f Y//�J�Y/�(1 �QA� City IA-W,' Lot Size PM / f' Owner's Name (!i 6,04112 - &A?O (./AZA A /gdd. J�4 cad 4 4D'/1✓(' Phona - _ 61L Z?S Contractor bdi✓Al-d &MA"MI °Address License No. Phoned TYPE OF WEUIPUMP: __:NEW WELL_. WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION H SYSTEMREPAIR_aOTHER O -- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS lK ktdustriel Ad vG Y6Pi ❑ Open Bottom ❑Manteca Dia. of Well Excavation Dia. of Well Casing Z' - O Domestic Private ® Gravel Pack R1 Tracy Type of Casing ?U�-. Specifications ,. ... ❑ Public ❑ Other ❑ Delta Depth of Grout Seal o - `' Type of Grout ❑ Irrigation �_�Zpprox. Depth ❑ Eastern Surface Seal Installed 1�0 so C. Repair Work Done ❑ Type of Pump H.P. State Work po/rte Well Destruction ❑ Well Diameter L -� Sealing Material (top 50') '"^`� "` �')'� "�O -�aSf ZYf-O-Zy,� Depth_ Filler Material (Below 501 tL3 i"Ao•.+e )ett SSD o..S- -f.c. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION O (No septic system permitted 8 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 ❑ I hereby certify that 1 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 perk 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 subcontracting 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 must call for all required inspections. Complete drawing on RJeverse side. p Signed 1Title: � Date: FOR DEPARTMENT USE ONLY Application Accepted by ` lj� � Date �i Ana / 7 Pit or Grout Inspection Y ynn - Oats Final Inspection by / Data Additional Comments: //,PII"VA S/uRPaAH. nr,41 di!VS�O(?r }70170/✓�A 2e-1 ❑ Stk 166-Ml ❑ Lodi 389-3621 O Manteca 623-7104 O Tracy 8358385 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 CCKASH RECEIVED BY DATE PERMIT'NO INFO EH 1324(REV_1,'n5, EH 1426