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k APPLICATION FOR PERMIT Al SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 , 't 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 17q,70 1700.)70 6rar1b RA Aid sh Cityy t 466_ Lot Size - PM I Owner's Name X�t4y � Q- Address 2!7 6®rge, Phone Contractor's Name v`Q License No. 2-j(2_.Z;A:� Phone TYPE OF WELL/PUMP: 14EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �— .. - - - - - -. � -. - --r. PUMP INSTALLATION❑ wSYSTEM REPAiR �OTHER'❑" DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL�I OTHER WELL -- 1 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O-Industrial-- --E-Open-Bottom^-^^—E-MantecaDia-of Well-Excavation- - Dia. of Well Casing -- ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 'Specifications ❑ Public.A :tit ❑ Other. =�} t-t►O Delta Depth of Grout Seals '. ' ` ``, Type of Grout ❑ Irrigation- ---Approx.-Depth----!E Eastern Surface-Seal Installed-by-- �- --- ~� Repair Work-Done ❑ Type of Pump• � - .j H.P. I --State Work,Done aft. .:t 1 $ - W � Well,Destructibn F-1WellDiameter-�"t i 1 Sealing Material Itop 50'1 �^- --• Depth t Filler,Material-I-Below.501 TYPE'QF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ DITION DESTRUCTION ❑ INo septic system permitted if public sewer is � available within 200 feef:l" Installation will serve':' Residende Commercial_ Other Number of living units:Y_ Number of bedrooms " h oty Water table depth'o Q.-•� I Chara"cter.of^,.� r` soil'to a depth of 3 feet: - i SEPTIC 74NK--"""{ u0#,Type/Mfg 1 Capacity ^-'No. Compartments PKG. TREATMENT PLT.❑ r Method of Disposal v I Distance to-nearest: Well Foundation Property Line LEACHING-LINE ❑ No. & Length of lines — - .Total length/size N FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS C1 Depth —Size3A f y Y umber SEEPAGE i SUMPS _ Distance to nearest: Well Foundation�( � Property•Line. DISPOSAL PONDS El PL"�J 1., (A)ts_f I' r 1 ! I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquincounty 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 shalt 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 st call for at reg 'red inspections. Complete drawing on reverse ide. �-`�---"- i Signed Title: R Date: 1 L/leC, x7 FOR DEPARTMENT USE ONLY ff t Application Accepted by Date 1 = � Area (� or Grout Inspection by Date f� �y� Final Inspection by r� # Date �� Additional Comments: y w — ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-5385 *x Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton A+ie;,_P.O._Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED GASH KS RECEIVED.BY,. ,^. DATE PERMIT"NO. INFO +Eh 13-24 tREV.101831 c �� • E EH 14-28 '�1J - I 5