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r APPLICATION FOR PERMIT Y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA 1 Telephone [2091 466-6781 PERMIT EXPIRES TYEAR 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. �C�CJLu1d� PM _ Job Addres�J-3_5S l 0, EX-1,A06, - _ City l�l9� Lot Size Owner's Name Address�(� 55 l�� Jj �gcc Phona 333 r*u ' B � DZ_ Contract + r� ddress �.�.b� �,�� ! License-No.., 'f done TYPE OF WELL/PUMP: NEW WELL ❑ WEEL`L REPLACEMENT ❑ DESTRUCTION ❑ a r' PtfMf' I�lSTALLA710N ❑ (SYSTEM REPAIfi '© "OTHtR ❑ f s DISTANCE TO NEAREST:.SEPTIG TANK. SEWER LINES 'DISP.OSALIFLD.. L PROP. LINT=,' FOUNDATION' - AGRICULTURE WELL -OTHER,WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL {PROBLEI1�f AREA,.. CONSTRUCTION SPECIFICATIONS � ❑ Industrial L3 Open Bottom 0—Manteca", Dia. of Well Excavation`' ,,L' r -t. * Dia of WeIP.Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of,Casing Y.-.Specifio3�ions� ; r C1 Public Cl Other .`Cl Delta_ Depth:of Grout Seal. Type of Grout 4 i I Irrigation Approx. Depth= l 1 Eastern T Surface Seal Installed~by' '' x �d"r -� 1']t'}� fff Repair Work Done 'CT't�Type af,Pumpr"`H.P:' '" State Work Done^ Well Destruction ❑ Well Diameter 4 Sealing'Material hop 50'1 Depth 4 Fiiler�Nlateri (Below §01 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR .'DpI,TION DESTRUCTION I I (No septic system permitted it public sewer is 'f" '• available within 200 feet.) Installation will serve: Residence? Commercial . Other ` 1 Number,off living units: _/_ Numb f bedrooms •) +-0- "'' Character of soil to a depth of 3 feet: Water table depth "I" r SEPTIC TANK Type/Mfg t Capacity,�c04 No. Compartments PKG. TREATMENT PLT. ❑ r .+'J , r r Method of Disposal "'Distance to nearest: We11 7L� Foundation LIAO Property.Line - LEACHING.LINE ` No. & Length of lines 4 ' L40j Total length/size FILTER BED:" ❑ Distance to nearest: Well� Foundation " 1 D Property Line i SEEPAGE-PITS Depth Size Number SUMPS rF ❑ Distance to nearest: Well_A001 Foundation 1 U r Property Line _ •�j 4 t DISPOSAL-.?ONDS L7 - - I hereby certify that.1-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 Dittrict. t _ Home owner or licensed agents 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 fo 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 mu call for a wired inspections. Complete drawing on reverse sid Signed X Title: \2- Date: �_- FOR DEPARTMENT USE ONLY AP lication Accepted by 9 Date W Area or Grout Inspection by ate '9 'Final Inspection by Data Additional Comments: w i ❑ 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 PERMIT'NO. �.EH1324 IREV. EH t4-28 i ..