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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA �� Telephone (209) 466-6781 RECEIVE® r PERMIT EXPIRES 1 YEAR FROM DATE ISSUMR 0 7 WO (Complete in Triplicate) SAN JOAQUIN CGUNT`! Application is hereby made to the San Joaquin Local Health District for a permit to construct and/orlW&kaeHFdW*e ii.rolRis application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/ �$dlV+ll;[[IU 16uWiJhe San Joaquin Local Health District. Job Address t^ --i-"Nhio n Shre.ef /�,�City Lot Siz4450JP-1L:S PM e ! _ l / ,, Zpq I Owner's Name � Of "Ql1`fC,CLX__ Address I00I � Phone Z-34 S ` - ! , I `f i Contractor J�Pe_G- -Lt ey-% Address 282.E E•Mwr4lfe JT 4 License N�o.rS�Phone_q,41- 1.345- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER SO"- Q?8(cl/U�s DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 7555 DISPOSAL FLD}�d PROP. LINE ?!50 FOUNDATION AGRICULTURE WELL'� OTHER WELL�5c0 PITS/SUMPS>—CO INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ❑ Industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excavation ro Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ki/A ' Specifications C.�erl f'r- f'l Public F1 'Other ❑ Delta Depth of Grout Seal n20—ag Type of Grout 8c, n 4Cj I I Irrigation -Approx. Depth I I Eastern Surface Seal Installed by SIPec4rue-ri _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 501 CCcwrfnf `krj e-0 C& Depth cx,-as Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION 1.l DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms C Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments p PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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 foII6Wing:"I certify that iii the peiformar>ce 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 applic ?/m st call for it quired inspections. mplete drawing on reverse side. Signed !� �'� Title: T CC41C3 S Date: ` 6 9 �� FO PAR IIE SE ONLY Application Accepted by ' }1 Date / 2 Area � /� Pit or Grout Inspection by l 1C Date Final Inspection by 3/Z 1 !� Dat-5_& D Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO a.EH 13-24(REV.t/A5) EH 14-28