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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE4 T ON 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. �.� Jab Address 05M Y"�A�• City LLJ[JI i — Lot Size PM Owner's Name LbA Rko- Address 1423 ?1.6 M, (400;4Z Phon4Z13 Z35 SAY" DC-:il1A 505_*Contractor Address b Aw– License No.3-7q"150 Phon lszb X15 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT EJ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEMREPAIR ElOTHER Pf Mon;+orr n� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES a2O' DISPOSAL FLD. PROP. LINE FOUNDATION "` AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it F] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 9" Dia. of Well Casing r ❑ Domestic/Private X Gravel Pack ❑ Tracy Type of Casing I+• q0 P.V + Specifications El Public ❑ Other C1 Delta Depth of Grout Seal On i•J�Type of Grout ElIrrigation F) r q!Tf ox. Depth ElEastern Surface Seal Installed by – rA<- .tirRepair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is L� 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 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 applicant must call for all required ins o s. o plat drawing on reverse side. U -7 A le - -�3-�3`7 Signed �� e- Title: � d � � Rate: FOR, A SE ONLY Application Accepte Date Area Pit Grou ion by Date Fin Inspection by Date Additional Comments: ❑ Stk 466-8781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-BM ' Applicant- Return all copies 09 ronm ntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20 , Stk., CA 95201 t y 1 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT''NO. INFO CASH + EH 13-24 1REV. //851 3� � �-S%. �� I 5 , � F7 41" 1 EH 14-28tj� "'lll !` 3,�4D