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APPLICATION FOR PERMIT l v Y Z� t SAN JOAQUIN LOCAL HEALTH 'DISTRICT `i (—Q 1601 E. HAZEL i ON AVE., STOCKTON, CA V" 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 Rules and Regulations of the San Joaquin Local Health District, Job Address ; ra,v City 40 5:2( Lot Size PM tQ Owner's Name f,[l/N Address �� 4G/V Phone Contractor's Name C E'lca7 f! y—f! License No,-� Io��' _ Phone TYPE OF WELL/-PUMP.;_:, , __NEW_WELL'10 WELL'-REPLACEMENT-El—DESTRUCTION-0 PUMP INSTALLAT ON ' SYST M REPAIR ❑ OTHER ❑ DISTANCE,TO NEAREST: SEPTIC TANK N� SEWER LINES f�aN'� DISPOSAL FLD.�@ J,9' PROP. LINE `� FOUNDATION AGRICULTURE WELL�, OTHER WELL NCl n/� PITS/SUMPS /6'e44 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it " ❑ Industrial XOpen Bottom ❑ Manteca `' ,Dia. of Well Excavation /�2 "- Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing '.Specifications ,) I " ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ria�f- Type of Grout /IcLY Cetne ' ❑ Irrigation v��h� Approx. Depth 1:1 Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump G00W H.P. I r�L � 4". State Work Done ! Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 r . 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 1 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 l FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth :Size Number- 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 �F 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 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 must call for all required inspections. �Complete �drawing on reverse side. 'f Signed d,, a " "`�"-r Title: A0— Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �'�'�1� Area q_C Pit o Gro Inspection by `K��//6ru/ Data + C� Final Inspection by '`^"' DateZZ-2,1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-638.5 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 CK H RECEIVED BY DATE PE MIT''NO. + EH 13.24(REY.10!831 �� DLJ DO , pt11),&,, -s /( !/ ! ��} EH 1428