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PLICATION FOR PERMIT AP ' t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED tlC (Complete in Triplicate) s 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 Dist rict. (�Job Address Address J-I 25-T�� °'�y� City ` Lot Size hs x�1 S) PM Owner's Name AD(O L LD 'Address �- .� Phone �Z Contractor:6-1VL lll� l a Address i 38x ` dam �iiccense No. 37�SGrS Phone{_i l6 lo'f,�a1'3 TYPE OF WELL/PUMP: NEW WELL 1 r+0 ,r1fVEL ACEMENT ❑ DESTRUCTION ❑ AR Q/gyp/�Z PUMP INSTALLATION In �y'll0 SYSTEoE REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP" LINE- �.�,r(ilC� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS_= 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI S ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia" of Well Casing 2 ❑ Domestic/Private XGrave! Pack xilacy Type of Casing PV L Specifications El Public ❑�e,Oft�h�er ❑ Delta Depth of Grout Seal S/ T pe of Grout It igation : !Npprox. Depth ❑ Eastern Surface Seal Installed by �mrk Repai o(k Do"ne ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material IBelow 501 { 5 TYPE OF SEP WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Z available within 200 feet.) N C♦ stallation will serve: Re " ce_ Commercial_ Other V` umber of living units: Nu of bedrooms 11 haracter of sotl to a depth of 3 feet: Water table depth A TIC TANK ❑ Type/Mfg Capacity No. Compartments U TREATMENT'PLT. ❑ Method of Disposal Distance to nearest: Well dation Property Line �tHING LINE ❑ No. & Length of lines �Iength/size— FR.BED ❑ Distance to nearest: Well Foundationne Q zAGE PITS ❑ Depth Size Number QIP PS 11Distance to nearest: Well Foundation Property Line OSALL PONDS ❑ dI 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 p rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "1 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 vz 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 applican must c for all re uired inspectio s. C plete rawing on reverse side. 'l. Signed X Title• i Date: FOR DEPARTMENT USE ONLY c�` f_ Application Accepted by (�. Date Area V-7 " Pit or Grout Inspection by Date Date �� C) Final Inspection by T, ..-. Date Additional Comments. WG'O,TRAw&AA M /¢ 2 !OF/Z I-) Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -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 REMIT-TED CASH ED RECEIVED BY DATE PERMIT'NO. INFO } r EH 1324 IREV.t i w 5) 71:7iEH 14-28 + `+ 23;D i