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5 . FX-4 w APPLICATION FOR PERMIT � 6/rs PAYME:N-r /0-CF2 SAN JOAQU.IN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 MAY 2Z PERMIT EXPIRES T YEAR FROM DATE ISSUED ux, !Complete in Triplicate? ENVIRONMENTAL HEALTH Application is hereby made to the S4n ?oaquinealth District for a permit to construct and/or install the work hereiN descflt>f f`TA;4plication is 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, 2113 A%6 OZ ft-c-,91- Job Address EG S Igo ` ' D►771�sl-' City_Mf4N L-14 Lot Size �"Phone PM Owner's Name _ �I- �i� 7 Address t 4& 77 Olt phone Contractor /7? ddress 762,1:j: ,6 fi!y5,71, License fro.-17—Z68 Phone-qY6—L3qS7 _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE`ZZL--6rL/.r0 Cut /2 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS B L-C INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S +til$ ❑ Industrial 41, ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �p rt �yyJ F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation --Approx. Depth I I Eastern Surface Sual Installed by_ _ _.� �T7 C� 17 4--,Ji 2-1—_ Repair Work Done ❑ Type of Pump H.P. Well Destruction ❑ Well Diameter Sealing Material atop 501 O /Ll Depth Filler Material (Below 501 c TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments mkA PKG. TREATMENT PLT. ❑ Method of Disposal \ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Gl Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS Cl 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 Dikrict. ! 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 ust call for alt r (red inspections. Complete drawing on reverse side. Signed X Title: Date: S--Z3—!io FOR EPARTMENT USE ONLY f Q Application Accepted by Date r f 3- Area J, / U Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY (DATE PJpERMj IST''NO. t.EH 13-24 1REV, H 51 —3S'bt7 Sul