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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) 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 Ordinar ce No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /)/� ' I/Job Address I �/ r'� ! An a ki Cit l i •S Y Lot Size pM �l Zee (-Owner's Name G+Tc� '1'1Address 5_1 Phone �Cantractor Rkr U IJO-" -La,� Address ex ,LJO �Ir L_____License No. Phone TYPE OF WELL/PUMP: NEW WELL-X 7q.00 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION T"OD SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK INSTALLATION LINES 7 ] ISPOSAL FLD.� � PROP, LINE ECS FOUNDATION i'JD AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYP OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavati r Dia. of Well Casing' J(Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal SU Type of Grout QA , I) Irrigation _-Approx. Depth I I East r Surface Seal Installed by Repair Work Done E3 Type of Pump sem: A H,P. 5 State Work Done Well Destruction 171 Well Diameter Sealing Material.ltop 50') �} Depth Filler Material (Below 50') TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 RE IR/ADDITION I t DES UCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ er Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water tabte depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Fo dation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ell Foundati Property Line SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to ne st: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 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: "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 applijAccepted required inspections. Complete drawing on reverse side. �J Signed X Title: ;/ )kw-,(.. Date: it 1 P FOR DEPARTMENT USE ONLY 1 ApplicatioDate !1' Area It l-� Pit or GroGam,- Date Final Inspection by Date 4 Additional Comments: Lg/9/iJ ❑ Stk 466-6787 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,P.O. Box 2009, Stk., CA 95201 FEE UNT DUE AMOUNT RIT EMTED CK RECEIVED BY INFO �7 DATE PERMIT'NO. +.EH1 -24{HEV,rin51 OSe//�� J ./i `l� 1/ //— EH 144-26 V 11,,....�J D( Y/�/ X?