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F APPLICATION FOR PERMIT-"-- { 1 Z tl SAN JOAQUIN LOCAL HEALTH DISTRICT +.vim J 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �TA�- HEALTH (Complete in Triplicate) E�� M1�/s6oJIGES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. TMs 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. ,. V Job Address City 40L2 Loi Size PM Owner's Name +� -� ,1 rAddress � — Phone ��g Contractor /�/d�iP/�J�/US Address_2�fa� ;:�/i4GO . ''License No. 88lC� Phone4;9 ? TYPE OF WELL/PUMP:N-,, NEW WELL ❑ WELL'REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ _ SYSTEM REPAIR.❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.I PROP. LINE ,_,FOUNDATION AGRICULTURE WELL, -N.- OJ.HER WELL, PITS/:SUMPS ._.... INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP CIFI NS r„ ❑ Industrial ❑ Open Bottom C3 Manteca Dia. of Well Excavaiion Dia. of•Well,Casing""��1 "Domestic/Private ❑{GraueljPack Ll Tracy Type of Casing Specificationts El Public �❑ Other 71Delta Depth of Grout Seal Type of Grout 'I I ❑ irrigation ---Approx. Lioth El Eastern Surface Seal Installed by\ 1 t t Repair Work Done ❑ Type of Pump :5bB H.P. /T_ State Work Done � //lam Well Destruction ❑ Well Diameter Sealing Material (top 50'1 ! j S;� L IV xU Depth Filler Material (Below 50'1 __._. { TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION l❑ (No septic system permitted,if,public sewer is l available within 200 feet.) i Installation will serve: Residence_ Commercial_ Other v dI ,. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 4 SEPTIC TANK ❑ Type/Mfg Capacity ; No. Compartments _ PKG. TREATMENT PLT. ❑ Method of Disposal Distance_to nearesLell. � Fbundation Proper 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 Cl 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. C 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." A The applicant mus f r a required inspections Complete drawing on reverse side. Signed X Title: Date: r ' j a FOR DEPARTMENT USE ONLY Application Accepted b iS6, Date V `� ` Area z Pit-or Grout Inspection by Date Final Inspection by •Date Additional Comments: ❑ Stk 466-6761 ' ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED 8Y .DAATEE� PPEE�RM4T'NO. + EH 13-24 IREV,1/0 s) EH 1428 �: r