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v APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �— 1601 E. HAZELTON 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 Rules and Regulations of the San Joaquin Local Health District. l 6 Jab Address City Bre•�✓/v�lnJ 6s'KA'Ld71� Lot Size 1/d PM Owner's Name Vk I—IJET W Address —1 571 5-1 gll;Pluvl &A,,, Phone -1496 Contractor's Name License No. n Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ; • I PUMP INSTALLATION 11 -- SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK ` SEWER LINES _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA $CONST_RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca i Dia. of Welk-Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type t T e.of Casing Specifications ❑ Public E3 Other1-1Delta f Depth of;GroI t Seal r r Type of Grout❑ Irrigation _.-__-Approx. Depth... ❑ Eastern y ' Surface SealInstalledby Repair,Work Done ❑ Type of Pump } H.P.i7 ' r ' State Work Done Well DestPuction -El. Well Diameter Sealing Material (top 50') .� -Depth Filler Material (Below 50') e I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ 'DESTRUCTION ❑ (No septic system permitted if public sewer is ` � Ilk, -` . i `available within 200 feet.) Installation will serve: Residence— Commercial_ Other � .....a ' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: L4 M C ��,,-A� € Water table depth 6/ SEPTIC TANKS Type/Mfg �N�'=ta ci Z zoV ArtNo. Compartments PKG. TREATMENT PLT. ❑ Method of DisVosal Distance to nearest: Well Foundation !�. f Property Line i No LEACHING LINE J . & Length of lines ' i rrata/ length/size FILTER BED E3 Distance Distance to nearest: We111eF uo ndation " Property Line V....�. . ..._. , - . r. SEEPAGE PI75' "" ` "`❑ Depth Siz - Number — -- NSUMPS Distance to nearest: Well {Fouridation�` pity T ,J4"� f 1D f ,Pro e. Line y 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 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." I. The applicant most call for all required ins a !ons. omplete drawing on reverse si e, •c Signed , Title: Date: d k FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Data h7�y Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 �It r� c Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a+{-ec f J y1}.Z TyjW,,-. C o v c 4�� (1 -c. FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY " J INFO !! CASH DATE PERMIT"NO. 1-t W + EH 13-24 MV,101831 EH 1428