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A. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. �ly�,QS�GT/.ON Job Address _,Y2 Mj� �/9S/ ��h?G/�RD¢ 99,gsASi city :5 l Lot Size «le2elr!E4 PM rReAmnn 5E Owner's Name 40-5 CA//7/ ,EEeJ J 1/2 Address 6J'? 1y 41,2!Y STir2�� Phone Contractor_ 11,e/1'�is Wi4TF.� Address Z�?� j,4A I �Y �� License No. 4Z�8!lo Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION XV PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .: ._DISPOSAL FLD_ — PROP. LIME--_o� JE FOUNDATION' AGRICULTURE`WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y ElIndustrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing JZ ❑ Domestic/Private ❑ Gravel-Peck- - ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ;Z_ Approx. Depth ❑ Eastern Surface Seal Installed by r ,Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 S64/6_,ef-ZE WCL L Depth Filler Material (Below 501 „J,4�L2X A"Ilk-- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number A N SUMPS ❑ Distance to nearest: Well Foundation Property Line 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.forwhich 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." -- applicantThe required inspections. Complete drawing on reverse ide. Signed m11 Dell for -� � Title: Date: " 1° FOR DEPART4tNT USE ONLY Application Accepted by Date *�� J Area O Pit or Gro nspection by Date Final Inspection by Date �� d ' onal Co.,ments: tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 4b Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 p FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT`NO. INFO CASH + EH 13-24(REV.1/85) -70 I r��/ a7 EH 1426