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�r p Is �S • li. +� APPLICATIOWFOR PERMIT Kko 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA "Telephone (20466-6781 1 PERMIT EXPIRES`1 YEAR FROM DATE ISSUED ' (Complete in Triplicate) �; Y 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. I' Job Address ,�, �r2�I L� / ' _ City 45"7/ V .— Lot Size -2.0 PM Owner's Name 1 Address N Phone Contractor_. rF4-0 r/D E• !!1000z Address J- IJ*, LL ,(,J AWd�ryZL_Phone License No. TYPE OF WELL/PUMP: [NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation e Dia. of Well Casing ,4 El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ISpecifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal I Type of Grout I ❑ Irrigation _i'!Approx. Depth ❑ Eastern "Surface Seal.Installed by I I Repair Work pone EJType'of Pump H.P. # State Work Done_ Well Destruction ❑ Well Diameter Sealing Material,(top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence!!/Commercial— Other M " Number of living units: Number of bedroomsr Character of soil to a depth of 3 feel: + SEPTIC TANKWater table depth Type/Mfg _ Capacity No. Compartments �— PKG. TREATMENT PLT. ❑ ay Method of Disposal Distance to nearest:i '-Well Foundation 'Property Line LEACHING LINE' ❑ No. & Length of lines h Total length/size FILTER BED ❑ Distance to neare'st:�-'-"""Wel! i Foundation h PropertjrJLine SEEPAGE PITS ❑ Depth Size Number SUMPS M. Distance�to nearest: Welly r I Foundation ° A Propen,"Line k DISPOSAL PONDS ❑ �I d 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.. L ... 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 em lo tion laws of California." I p y persons subject to workman's compensa The applicant must call for all required.inspe S. Complete drawing on reverse side. Signed X Title: Date: ^n FOR DEPARTMENT USE ONLY Application Accepted byt1„ ^1, -^ w ^ Daterea Pit or Grout Inspection Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 El Lodi -3621 ; ❑ Manteca 823- ❑ 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 AMDUNT REMITTED INFO r-7N CK RECEIVED BY�4 DATE PERMIT'NO. + EH 14-24SREV.lin51 .,o 0 ()� � J _ co� EH 1428