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1 �,. APPLICATION FOR PERMIT �53 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA :�4 Telephone (209) 466-6781 ` J PERMIT EXPIRES TYEAR 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 flegulatioris,of;iFie$ariaoaquin ' Local Health District. Jab Address X3181 r `� �� r ., ' City Lot Size ply [ s ¢ c q .Owner's Name)£1-14 ' E lfl- J30A,1 S i Address Phon Contractor D� �.c..y rV Address VC RC1 License NoA 13 73 Phone TYPE OF WELL/PUMP: . NEW WELL LJ. . WELL REPLACEMENT ❑ DESTRUCTION ❑ I 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 f[ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well'Excavation I7 Domestic/Private ❑ Gravel Pack -❑ Tracy Type of,Casing Specifications f-i Public C1 Other L1 Delta Depth of Grout Seal I I Irrigation Type of Grout --Approx. Depth I 1 tern Surface Seal Installed by Repair Work Done �- Type of Pump —_Ears H p I� Well Destruction ❑ Well Diameter State Work Done M Sealing Material Itop 501) ' Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION i I DESTRUCTION ( I (No septic------------- system permitted if public sewer is ! Installation will serve: Residence— Commercial— Other available within 200 feet.) Number of living units: Number of bedrooms , t Character of soil to a depth of 3 feet: ~�T--� -' -'SEPTIC TANK Water table depth ❑ Type/Mfg ° C PKG. TREATCapacity No. Compartments �, _ MENT PLT .� .:�' _ .x r Method of Disposal V! Distance to nearest: WellW � "- ' - Foundation Property Line i LEACHING LINE ❑ No. & Length of lines FTata! length/size FILTER BED ❑ Distance to nearest: Well Foundation . � � Property Line SEEPAGE PITS I I Depth Size t SUMPS ❑ DiNumber Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line r 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: "Icertify 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 Californ• .' M The applicant m 11 f all required spections. Complete dare signed X Ing on reverse side. le: �r l�•--�� ' F EPARTMENUSE ONLY Application Accepted by � Data Area Pit or Grout Inspection.by Date G Final Inspection by--� ` Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma teca 823-7104 ❑ Tracy 835-6385 Applicant - Return 811 copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FSE AMOUNT DUE CK INFO AMOUNT REMITTED CASH RECEIVED BY DATE jPERMJT'N]0.+ EH 13-24iiiEV.iiHSYC, EHt4-ZBq