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� � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) /-0—r of ge_a".o,QA 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 welt/pump and the Rules and Regulations of the San Joaquin Local Health District. 7 /.� � Et/X SPM -7Z6� �— City � ��" �of Size �b Address � �_ �J Owner's Name LK 1� �`q 1-5 IJ -� ess — �t 1"1 Phone 6 `Q 1- ontractor Address License No. Phone TYPE OF WELL/PUMP: III NEW WELL ❑ WELL REPLACEMENT E.] \ CDESTRUCTION ❑ l PCJMP1NSTALl TION"❑""" .=r:. --SYSTEM REPAIR-CCy r-�-•'�"�""`*-,pTHER•C]"�--�-�- DISTANCE TO NEAREST: SEP IC TANK SEWER LINES- ' --DISPOSAL-FLD.-- = PROP. LINE } i F061,NDATION AGRICULTURE WELL OTHER WELL—,PITS/SUMPS. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial s a ❑ Oberi Bottom ' '❑ M"aRteca Dia. of Well`Excavation "" Dia. of Well Casing ._ LJ Domestic/Private L1Gfavel Pack ❑ Tracy Type of Casing --- '`Specifications'} t� -1 Public ❑ Other 171'Delta # ,Depth of Grout Seal t '" w Type of.Grout ' IIrrigation 4pprox:•"Depth--1-I-Eastern Surface-Seal-Installed by � �- Repair,Work Done ❑ Typel of Pump H. ! State Work Done, Well"Destruction ❑ Well�Diameter Sealing"Material (top 50') _ �`` Filler Material (Below 501 TYPE OF'SEPTIC WORK: NEIN INSTALLATION i.l REPAIR lADDITIONA.I OESTRUCTION"l'1•INo septic system permitted it public sewer is t ►� } JF available within 200 feet.► ifi Installation will serve: Residence_X Commercial's Other e ~`� `�� 1^.. Number of Living units: _._,,I�,�I Number of bedrooms t+ i F . Character of soil to a depth !f 3 feet: `- Water table pth -" SEPTIC TANK ❑. TypelMfg ;d�5['I'S7 i��r Capacity a�� No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal l { Distance-to nearest: -Well--- " 'Foundation Property Line �,f ro' li oral len th/size % k LEACHING LINE L� No. fy Length of lines F 9 FILTER BED (Distance to nearest: Well Foundation _.__...__ Proparty Line _1 SEEPAGE PITS Depth _ Y Sire+ 5 Number SUMPSE500"6istance to nearest: Well Foundation Property Line—l�— t1f DISPOSAL PONDS'',\. ❑ hereby certify that I have pre$ared 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.'is 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 certifX that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." Theapplic t call for alequired inspections. Complete drawing on reverse side. 4 Signed X Title: Date: I FOR DE ARTMENT USE ONLY I� !�[^•i "Date / � �" Area " Application Accepted by Pit or Grout Inspection by '� - Date Final Inspection by`•Y l Dat./ Liu Additional Comments: El Stk 466-6781 Loltlli 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 -,p Applicant- Return all copies f': Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE Lf, UNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. INFO �.EH 13-241AEV.I/ 51 EH 14-29M II