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} APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601E. :HAZELTON AVE„ STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1 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 f 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. Job Address City City Lot Size Z/W G PM Owner's Name IX-6R y 4! &/M' ddress 2 Phone Contractor S Address 4" I % icense*No.;- / Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT U`1 �r DESTRUCTION ❑ PUMP INSTALLATION` SYSTEM REPAIR ❑ fr V ; OTHER 171i z DISTANCE TO NEAREST: SEPTIC TANK 2_�W� S. SEWER LINEDISPOSAL FLD.'--- PROP. LINE FOUNDATION AGRICULTURE WELL .� OTHER WELL �-r PITS/SUMPS �— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS., ❑ Industrial fl Open Bottom ❑ Manteca Dia. of Well Excavation Z[LDia. of Well Casing 4 X�Domestic/Private >(Gravel Pack ❑ Tracy Type of Casing r°. Specifications f"1 Public F1 Other I ❑ Delta Depth of`Grout SealType-of-Grout I Ifrigation r� pgrox,-9epth-_ I I-Eastern 5urfaca_Sealxlnstalle?1_by... f _ Repair Work Done ❑ Type of Pump H,P. _.' .C-- State-V11 [ Well Destruction ❑ Well Diamef 'rer_'�d:""� ^—Sealing Material (t AQ /op�50'I f _ --�"�'�-----__ Depth 3i k Filler Material IBelow 501 TYPE OF SEPTIC WORK�-<)NEW INSTALLATIONif I REPAIRYADDITON I I DESTRUCTION I I (No kleptic system permitted if public sewer is .a f availatiie within 200 feet.) 4 Installation will serve Residence — Co mer !� Other ]' § r � Number of living uni[s:/ � . s Number of bedroom '} °_fes W f• / Character of soil toga de thof 3 f et: #.--`I T table �p 4: Watedepth ' va SEPTIC TANK f ❑ Type/Mfg -^w---- apacity ___ No. Cornpprtments,�_1 _ -:- c> PKG. TREATMENT PLT. ❑ Method of Disposal j Distance to nearest: Well Foundation Property Line LEACHING LINE"""'❑'"-No &Length'�f-Iines — -- 4�, ` otaf length/sized - - ^� I FILTER BED ❑ Distance to clearest: Well Foundation Property Line { SEEPAGE PITS 11 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, and1 rules and regulations of the San Joaquin Local Health District. 12 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 i a requir ions. Complete drawing on rever &_side. Q Signed X Titre: Date: FOR DEPARTMENT USE O Y 44 Application Accepted by Date Area 0; i -I Pito Grout Inspection by Date�`a2�(.� 'D Final Inspection by Date � GS Additional Comments: iv ❑ Sik 466-6781 C] Lodi 369-3621 ❑ Manteca a23-7104' b"Tracy 835-6385 y Applicant - Return all copies to: Environmental Health Permit/Services 160 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT,D�U,Ey AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. + EH1324(REV.i/x5) EH 14-28 j—