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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT EL34C�t�rtC.f1L � a � 1�►"t►i S 2 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 �:'� Sot PERMIT EXPIRES 1YEAR FROM DATE ISSUED or WatA c Oat (Complete in Triplicate) bA, Rar w,.q_ 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 City L Lot Size 02 825 Sir PM NOwner's Name Address Phone( 534P CV ,S& 61'74> Lrit,6' Contractor 12 1w eb6AA� Address Q License No.4WZaa_Phone TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT" ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE R,<-riFf� �` h DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca - Dia. of Well Excavation Dia. of Well Casing omg Iestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Public P'Ot r ❑ Delta Depth of Grout Seal 41 A-C92MA Type of Grout I I Irrigation �prox'. Depth I I Eastern Surface Seal Installed by _ .Q Repair Work Done ❑ Type of Pump H.P. State Work Done�� 'a T t Well Destruction ❑ Well Diameter '" & AC,6 Sealing Material (top 50'I )2._ (Aaw6A6& Depth_W50 FE Filler Material (Below 501 TYPE OF SEPTIC—WORK: NEW INSTALLATION l l REPAIR/ADDITION I I DESTRUCTION I I, INo septic system permitted if public sewer is R available within 200 feet.I Installation will serve: Residence Commercial_ Other �C Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: F J Water table depth SEPTIC TANK ❑ Type/Mf Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line \ .! i - f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line � A SEEPAGE PITS l 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 wilt be done in accordance with San Joaquin county ordinances, state laws, and n rules and regulations of the San Joaquin Local Health District. Home owner or licensed,agent's signattire certifies the following: "I certify that in the•performance of the work for which this permit is issued, I shall nott employ any person in such manner as tri 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 rflust c !I for a!I required inspections Complete drawing on reverse'side. Signed X y Title: `99Lft" Date: " FOR EPARTMENT USE ONLY Application Accepted byOL Dat��e�� 4 0 Area t Pit or Grout Inspection by Date Final Inspection bid DaterU . S Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNTDUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. + 13-24 (REV.iix51 EH 14-26