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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 t.44A2E;.TON`AVE., STOCKTON, CA Telephone 1209) 466-6781 -1 PERMIT EXPIRES.1 YEAR FROM DATE-ISSUED Illl.t. ft':i . (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 Joaqui6:County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and-Regulations of the San Joaquin l Local Health District. i . �r.ws t A. y �� Q F I✓T�2�E�?%4 / Job Address /T t,L City Lot Size PM Owner's Name ��/� 2EY,EAa��ddress 1l SD¢ fZ'LO/�'f 1�J� Phone t �G��JgTl�ieA/ �nlJ Co tractor �/P iS�i�/S' S r Address �/o?� A:2/_A C,a�icense No. Phone + TYPE OF WELL/PUMP: NEW WELL ,�NWELL REPLACEMENT ❑ DESTRUCTION ❑ l� PUMP INSTALLATION , SYSTEM REPAIR ❑ OTHFfR ❑ DISTANCE TO NEAREST: SEPTIC TANK , ZZ SEWER LINES DISPOSAL FLD. L 34:,- PROP. LINE Ip FOUNDATION �„ AGRICULTURE WELL OTHER WELL PITS/SUMPS INT ENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP,ECIF,ICATIONS �y ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation'_'_' 1Z_ rt Dia. of Well Casing Domestic/Private e9P Gravel Pack ❑ Tray Type of Casing G Specifications El (Public ❑ Other ❑ Delta Depth of Grout Seal ��4- Type of rout J4/ 177 ❑rIrrigation ;&22Approx. Depth ❑ Eastern 'Surface Seal Installed by Repair Work Done ❑ Type of Pump �FVA3J H.P. State Work Done 3 1 Well Destruction ❑ Well Diameter Sealing Material ftop 50'1 tC l I� Depth i Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 'DESTRUCTION ❑ !No septic system permitted if public sewer is l l available within 200 feet. Installation will serve: Residences Commercial Other ? t !. Number of living units: Number of bedrooms! �� Character of soil to a depth of 3 feet: It Water table depth SEPTIC TANK ❑ Type/Mfgi Capacity No. Compartments ` 6 h f r i; PK6. TREATMENT PLT. Eli S C Method of Disposal Distance to nearest: Well Found ati Property Line :} i r LEACHING LINE ❑ No. & Length of lines �� Total length/size FILhTER BED ❑ Distance to nearest: Well I Foundation Property Line it ► 0. N" SEEPAGE PITS ❑ Depth Size__- 3 !Number SUMPS ❑ Distance to nearest: Well lF-aundation P_rpperty_Line - � DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and"thwvthe work will bewdone_ain accordance with_gan Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health pistrict. - <� Home owner or licensed agent's signature certifies the following: "I certifylthat'in_the performance a work_for which this permit is issued, I shall not employ any person in such manner as to become subject Ito workman's compensation laws of—CW—if orma.'%tontractoes hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is is�ued,I shall e 6 ploy persons subject to workman's compensa- tion laws of California," The applicant f all requi n pections. Complete drawing on reverse ode. { I . Signed X Title: � Date: l � DEPARTMENT USE ONLY Application Accepted by Date e4—4- '-VJ Area Pit or Grout Inspection by Date Final Inspection by� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 AFEE pplicant- Return all copies tv: Environmental Health Permit/Servic601 E..Haz�eiton Av�.,_P.O.Box-2009, Stk., CA 95201 INFO AMOUNT pUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. + EH 13-21(REV.1/ 5) EH WA _ s