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APPLICATION FOR litRMITc SAN JOAQUIN.LOCAL HEALTH DISTRICT ° 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED v (Complete in Triplicate) .. 5.. Application is hereby made to the San Jpaquin 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. r Job Address J O 77, !e,M S c N L.J. tr City MC Lot Size PM Owner's Name D14-o- A v.�� Address Phone"O ��y Phone 1-3.0 Contractor All 4)� 6 V l'a/4 Address • 0 o- d !r License No.>S�j_ % Phone -3 6 Y ` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ - SYSTEM-REPAIR ❑ OTHER'❑ —_ DISTANCE TO NEAREST:SEPTIC _TANK SEWER LINES s DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED-USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j 4� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private El Gravel Pack El Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx..Depth ❑ Eastern Surface Seal lnstalled_by �. Repair Work Done ❑ Type of Pump H.P. t State Work Done Well Destruction ❑ Well Diameter Seating Wterial Itop 50'I k. Depth Filler Material (Below 50'). E i TYPE OF SEPTIC WORK: NEW INSTALLATION E IO /ADDITN DESTRUCTION ❑ (No septic system permitted if public sewer is 4 f - available within 200 feet.) Installation will serve: Residence— Commercialo� Other ' Number of living units:V Number of bedrooms r k Character of soil to a depth of 3 feet:? t S ' Water table depth' Q SEPTIC TANK ElType/Mfg S �_. Capaci; +7 c No. Compartments PKG. TREATMENT PLT. ❑ { 4TH. -,S's�n►f S+wt-vr •,'� I Method of Disposal ._ Distance to nearest: Well Foundation / 0-,/- Property Line_./iD -0- _ x 14 - LEACHING LINE ) No. & Length of lines Total length/size FILTER BED �.- ❑''-- Distance to nearest: Well Found on "Property Line f o � T— SEEPAGE PITS _ 1 t Depth Size 3 3 Number SUMPS ❑ Distance to nearest: Well Foundation- 7e- Property Line /19 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 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 MIquired inspections. Complete drawing on reverse side. Signed X � i Title: ,- 1�,. - (/vim�L.Y 'T tN"V Date: fo ,Q A441Q yc� 1 h eeCk A- , FOR DEPARTMENT USE ONLY Application Accepted by Date"JZ reaPit or Grout Inspection by Date 1Final Inspection byAdditional Comments: Q 1 A!, ❑ Stk 466-6781 ❑ Lodi 369 ❑ Manteca 823 04 ❑ TrIcy'.835-6385,, Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton LAve.,`P.O. Bax 2 Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO RECEIVED 9Y DATE PERMIT'NO. -+ EH13-24(REV.1/R sl r EH 14-28: S•. �? 0 r. S 1��I - {SZS—IS 1 ;