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APPLICATION FORPERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRE81 YEAR FROM DATE ISSUED (Complete in Triplicate) `? p i 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 r 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. Job Address .5 aRl0 Ci -�— � � < ty�� J13%EGA L'ot Siie PM // Owner's Name gI Address f t� r zA7 W AVA� R,f4,7�ne 'Contractor's NarrieLicense No.'- ,- -�� o�•�� --'-.__�""' ,""" Phone' o? _•l - i 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 I INTENDED USE TYPE'OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' W ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private C1 Gravel Pack ❑ Tray Type of Casing�' Specifications v r ❑ Public ❑ Other Q Delta Depth of Grout Seal Type of Grout ❑ Irrigation �A ? �o g pprox. Depth ❑ Eastern Surface Seal Installed by { i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 y Depth Filler Material (Below 50'1 i r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION IDDESTRUCTION Ll (No septic system permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence X_ Commercial, Other Number of living units:__�_ Number of bedrooms y Character of soil to a depth of 3 feet: Water table depth ; SEPTIC TANK 1 Type/Mfg Capacityow _ No. Compartments t PKG. TREATMENT PLT. ❑ S Method of Disposal Distance to nearest: Well Foun ?� dation t� Property Line_,ZAA2,�! LEACHING LINE - /size No,„,& Length-of-lines. '� — - :Total length size r` FILTER BEDh Dist6ce to nearest: Well 16"t F Foundation 2=7 Prc pertyLine�$-� 77 SEEPAGE PITS ❑ Depth ` Sizes Number l SUMPS ❑ Distance to nearest:.,j Well Foundation Property Line DISPOSAL PONDS: ❑ 1 -ill „� I hereby certify that''I have prepared this application and that the work will tie done ir�Rc_o_rdance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.t •` 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 req 'ed ni s ctionsi Complete-dfiwing'on rever"s"e side:""` Signed E 1 Title: - _ Date: i z -- FOR DEPARTMENT USE ONLY f Application Accepted by 1 _ ,.,, Date Area Pit or Grout Inspection by - N Date Final Inspection by mal c1.t,.� pate Additional Comments: ❑ Stk 466-8781 ❑ Lodi369 3621 E 35- Manteca 823-7104 ❑ Tracy r 86385 Applicant•=-Retum-all copies to--Environmental'Health-Permit/Services 1601-E.'Ha2eiton'AVe., P.O._ Boz 2009, Stk, CA 95261FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATEAMOUNTPERMIT N0. + EH 13-24 MEV.10/831 , .. .•;:` Nb - Cr-(rp- 7 N4462- EH N446[EH 14-28