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I I APPLICATION FOR PERMIT 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) 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. Job Address WL City iZ Lot Size PM Owner's Name 6 4 V 9Z.,_ dress (� tet! 1�� phone �� 16 S t Contractor - - Address �7 �� 't:J'� tJ4 se No. ��_/45 one 3�' 3 TYPE OF WELL/PU P: NEW WELL` WELL REPLACEMENT ❑ DESTRUCTION ❑ { PUMPtINSTALLAT{0 ❑ SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES / DISPOSAL FLD. ky PROP. LINE 1 t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMP$ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ;Nye .qG ❑ Industrial !>Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing O `domestic/Private /❑_Gravel Pack ❑ Tracy Type of Casing__--.5194-e .. Specifications 11 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout ! I Irrigation f ( vGb rApprox. Depth I Eastern Surface Seal.Installed by ISfi g Repair Work Done_,)+[ Type of Pump H,P. i tate Work Done f t Well Destruction � ❑-,�-Wel!-Dia Sealing Material {to 4 - r De Filler Material elow 501 ` TYPE OF SEPTIC;WORK: NEW INSTALLATION [] REPAIWADDITION 1 1 DESTRUCTION I I JNo septic system'permitted if public sewer is : .} available within 200 feet�1 l Installation will serve: Residence Commercial_ Other '64 Number of living unfts �f °F i Number of bedrooms t k Character offsoil-to-a--dept\h,of-3�-feetf Water,table depth SEPTIC TANK ❑ Type/Mfg Capacity ` -'No. Compartments I„ PKG. TREATMENT PLT. ❑ r Method of Disposal ' r ,..-rDisiarTcee o ares"t Vl7e11 "' i Foundation Property Line LEACHING LINE ❑ No. & Lengthof lines Total length/size i r+ FILTER BED ElDistance to Weare - Well � Foundation Property Line SEEPAGE ITS 11 Depth Size Number Nb + 4 E T SUMPS ❑ Distance to nearest: Well Foundation Property Line Y DISPOSAL PONDS ❑ 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 a signature g: "! certify that in the performance of the work for which this permit is issued; I s agent's nature certifies the followin g g hall 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- I tionllaws of California." 4 Tha'applicant must required spection plate drawing on reverse side. ' Signed X Title: Date: �Q -- 00� i l FOR DEPARTMENT USE ONLY k _ Application Accepted by �y Data Area Pit cir Grout nspection by Date d Final Inspe tion by Date 7 Additional Comments: Ud4 t Fj3 O-Stk,4fiS=fi781.,.,_.r[❑-Lodi,.369-3fi2-1-- -D-Manteca 823=7104-�--�p.Tracj"835 6385�"�'^"" i Applicant- Return all copies to: Environmental Health Permit/Services 1601-E. Haielton.Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH K 9 RECEIVED BY DATE PERMIT'NO. +.EHt3-24 1REV,i/H 51 f EH}4-28