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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 (Complete in Triplicate) �3 L 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.649 for sewage or No. 1882 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. pr} Job Address 7� j L—L ✓A1//CO A." / City -TQC'✓ Lot Size PM Owner's Name 46)0)FA/a k8('1rr0 Ai,'/ Apddress 5/177C7 IL 4901`2 Phone - 93,4- Zlr " Contractor kwwv Biu/4tTe// Address License No. PhoneYl-r-.151-1610 TYPE OF WELL/PUMP: _ NEW.WELL JZ-_ _. WELL REPLACEMENT ❑. _. DESTRUCTION ❑ ., ------- _---- - -- __. PUMP IN§TALLATION�1 SYSTEM REPAIRS - OTHER-D 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 ® kWuetAal ❑ Open Bonom ❑ Manteca Dia. of Well Excavation Die. of Well Casing L - ❑ Domestic/Pr v to I� ® Gravel Pack IC Tracy Type of Cow- P U C- Spseifieabom ❑ Public [❑�7 `Other ❑ Delta Depth of Grout Seal C1 "2-•S ' Type of Grout () + N'`tr fi ❑ Irrigation Z,Approx. Depth ❑ Eastern Surface Seal c Repair Work Done ❑ Type of Pump H.P. State Wo Done Well Destruction ❑ Well Diameter 2 "' Sealing Material (top 50'1 e"` ^+ Z -Z Depth_ Filler Material (Below 501 Ntc•t S AMv ' - 4'Y TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted If public sewer is available within 20D 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. 8 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,Mate laws,and rubs 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 subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit is Issued,I shell employ persons subject to workman's compares- tion laws of California." The applicant must call for all required inspec�iions. Complete drawing onreverseside. Signed)t Title: l •�s,^i<-� /'V✓w�-c-�1.Z-� Date: L5A �� _S rte'///./L FOR DEPARTMENT USE ONLY Application Accepted by ��` Date //�7/S Ana aav Ph or Grout Inspection by/) / Date Final Inspection by l Date Additional Comments: Je,111114 } XWAO 1,�iJCs7L/? - if/lei/IFPCQE%d 14 �Oe r }�(1(ITO/✓KW ❑ Stk 466-Ml ❑ Lodi 395-3521 ❑ Manteca 823-7104 ❑ Tracy 835-5385 Applicant- Return all copies to: Environmental Health Pennit/Servk:es 1501 E. Hazehon Ave., P.O. Box 2009, Stk., CA 952(11 FEE AMOUNT DUE AMOUNT REMITTED k RECEIVED BY DATE PERMIT'NO. INFO CASH ♦ EH 1114(REV.I/e t i EH 1416