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. a►_ �p �� APPLICATION FOR PERMIT �I 0 N JOAQUIN LOCAL HEALTH DISTRICT I b 1601 E. HAZE i ON AVE„ STOCKTON, CA Telephone (209) 466.6781 Q PERMIT EXPIRES 1-YEAR FROM DATE ISSUED + (Complete in Triplicate) Applicati ereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is mad mpliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Loc ealth District. II ',I Job Address /i W,r�+ C t r r H�q"2 City SZx1�iaN Lot Size I ($O PM Owner's Name SlIiA L 01l.� +�eP;w Address CJ Wit OL ;- V�IP�MO % I- c�,9� 4/7 G-7�_ ! I b+e• 411W C(�Phone Caf�2+ r y L4.C1� 5 Contractor)DIE l►Vk E,'J f,J oeoAJ Address U i>Z z License No. -'y6 U(L-Z Phone !q l�-- 6-38 '2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER N'b ' '�Z r rv� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OFFWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Oppn Bottom ❑ Manteca Dia. of Well Excavation /01, Dia. of Well Casing ❑ Domestic/Private ❑ ravel Pack El Tracy Type of Casing- c- I`l Public i g Specifications Other L� Delta Depth of Grout Seal 2 3 Type of Grout I I Irrigation U_Approx. Depth l I Eastern Surface Seal Installed b C0AXV-11-j ST S Vr�ct, Jap y �--- Repair Work Done ❑ Type of Pump rt H.P. State Work Done_ Well Destruction O� Well Diameter Sealing Material {top 50') C 3 0E.,„ ; it1^f+Nr i� �Nta A� Depth�- �� y Filler Material (Below 501 . '> C TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is \1 I� available within 200 feet.) N Installation will serve: Residence� Commercial_ Other Number of living units: I. Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ' Water table depth ❑ TypelMfg PKG. TREATMENT PLT. ❑ Capacity No. Compartments Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE IN \ ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS �M I I Depth Size — Number SUMPS Cl Distance to nearest: Well Foundation DISPOSAL PONDS ❑ il. Property Line 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X y ./ . Title: 63�-,-�CC->C- Date: FOR PAR USE ONLY T ~! Application Accepted by I a_ // 3� �3 Date ! Ar Pit or Grout I pection by Date Final Inspection by Date Additional Comments: I� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Er"vvonmentel Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5tk., CA 95201 FEE AMOUNT 1.UE AMOUNT REMITTED INFO K RECEIVED BY DATE PERMIT NO. + EH13-24{REV.r i a 51 OY EH I4-28