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r APPLICATION FOR PERMIT'.. i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA,,, PERMIT NO. Telephone (209) 466-6781 DATE.ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a # (Complete in Triplicate) ` Application is hereby made to the Sand 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, E ZTA MLS ' Subdivision Name ' Job Address Owner's Name Address 3 1 T10_&7 A.) KIP0 Phone Contractor's Name � LicenseNo. Phone '"' Cb/ r- TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑1 DESTRUCTION❑ �� 47 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ;i DISTANCE TO NEAREST: SEPTIC TANK A SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION • ' AGRICULTURE*WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑industrial_ '-^ "� Open'Bottom Manteca f ^- Dia.of Well Excavation Domestic/Private ❑Gravel Pack ❑ITracy Dia, of Well Casing { i ❑ Public "� """- <' •--•'"��•'"'"' {,.�-❑Other 1 �. ❑Delta Type of Casing {. Irrigation Approx. ❑Eastern Specifications S Cathodic Protection Depth l Depth of Grout Sea] � ❑Geophysical Type of Grout 1 ❑Other. t Surface Seal Installed by f I Repair Work Done ❑ Type of Pump H.P. .., State Work Done Wel Destruction'❑ Well Diameter Sealing Material {fop 50') Depth s Filler Ma- te{�i (4116 w 50') .. � • TY•PE OF SEPTIC-WORK:"N£IiT INSTALLATION U REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is l : r, available within 200 feet.) ;Installation will sere: Residence C6mmercial Other : w-- Number of living units: 'Nof bedrooms Lot size f�7 �haract bf soil to a dee t 3 feet: Water table depth _ �-� - SEPTtC TANK'i ❑. Type'/Mfg�4`-'l` +� Capacity No.yCompartments PK0 4TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal {, _ SEWAGE SYSTEMC2 Distance to nearest: Well _�_ Foundation Property Line i •DESTRUCTION � � 'i LEACHING LINE.; i �p No. i Lfength of`tines Total length/size FALTER BED " t ❑ Distance to nearest: Wel �Foundation a Property Line _ SEfPAE *fS ❑ Depth f size _ 1 __ Number SUMPS ❑ Distancte to nearest; Well Foundation Property Line l DI{POSAL PONDS [� I•liereb). certify that I have prepared this application and that the work will be done in accordance with San Joaquin county or)linances, state laws, and rules,and regulations of the San Joaquin'Local Health District. I Home owner or licensed agent's signature certifies the following: "I:'certify that in the performance of the work;for which this pehmitjis,issued„ I shall not employ any person in such manner as to,become--subject—to-workmank compensation laws of California"' Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of ;the work for which i -this Orbit is issued, I shall employ persons•subject to workman's compensation laws of California." i i The applicant m ca for require inspections. Complete drawing on reverse side. 4 �'' s` Title: / .tib Date: Signed X r ( (; FOR DA ENT USE ONLY / Application Accepted by ]` /CN� � Area -._ L!Q—_— E] Stk 466-6781 kditionaltComments: _� F] 3 Lodi 369-421 Pit or Grout Inspection bye I date y 'Manteca 823-7104 Final. Inspgction by E Date ❑ Tracy 835-6385 Applican .t - Return all copies to:' Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ,FEE BASE AMOUNT.�UE AMOUNT REMITTED RECEIVED 8Y DATE PERMIT NO.- •a..:,...-..,:.,__._.�•:..-.-...-- -: 4 .... _, _. .1 . ..{- -�.---,:- 1 62 500 EH Z3-24 REV.10%8P 14-26 z.