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APPLICATION FOR PERMIT f' SAN JOAQUIN#LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone.{209} 466-6781 PERMIT EXPIRES'1 YEAR FROM,DATE ISSUED (Complete in Triplicate)'' "� "' ` "' tas` a ( ti t -1 #3tU4}0 entOUF301 :n 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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. -a ,y U13.Lql' 1'n .. . . • "}'.: y QED Job Address 34M AE- -6disa"_f 2,t� �_ ifs_ CityLot Size PM Owner's Name 1.1 N Dl4 PAC TZeOM Address 24�0 RD6J.N oeq &YJ_5,&19 ,,Phone A,�Q(1�. N ?}C5. _ t Contractor/� � s /�7f1LAddress gh�0 W✓il_4 [0}r' RP License No.4IaBZ16 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION flo 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 yr ,1 �Dlndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Don_e , �SuB r - Well Destruction ❑ Well Diameter i Sealing Material (top 501 ii Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is t available-within 200 feet.) Installation will serve: Residence— Commercial_____ Other i Number of living units: Number of bedrooms j + Character of soil to a depth of 3 feet: 3 _Water table depth f SEPTIC TANK ❑ Type/Mfg t ) Capacity No. Compartments PKG. TREATMENT PLT. 1-11 Metho`d of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total-Length/size-r"— j FILTER BED ❑ Distance to nearest: Well (,Foundation Property Line 1 SEEPAGE PITS ❑ Depth — w Size" /F -Number Y-- SUMPS ❑ Distance to nearest: Well 'FoundationzProper[y Line. DISPOSAL PONDS,., ❑ I hereby certify that I have prepared this apj;1Gtion and-that the work wile 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'worlCfor 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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit 19-issued,I shall employ persons subject to workman's compensa- tion laws of California." y r The applicant musticall r all re 'r d inspections. Complete drawing on reverse . Signed X a 'Title: r FOR,DEPARTMENT USE ONLY Application Accepted by Date , Area Pit or Grout Inspection by ! Data Final Inspection gyDate` Additional Comments: j } ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 El.Tracy 835-6385 Applicant='Return all copies to:Enviioninental H'eal'tFi Permit/Services 1601 E. Haiel3on Ave., P.O. Box 2W9,,Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY R l DATE PERMIT"NO. EH 13-24(REV.5/e 5) Ot' i.:.. r, _.�ys !i..,,-- N EH 1428 �'-