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APPLICATION FOR PERMIT 1r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. Job Address E)2,3 v ��a- er City � f Lot Size /� � t� PM Owner's Name Ir-red erZ/z Address I 10 �2S Q,00Y� Phone 23/ -JZ) ContractorCr Ad Address),!),�t3A"S 2Z/% 7c,4 License No. S3 1.23 Phone&3—SC'x3 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ �OTHER , ❑ / DISTANCE TO NEAREST: SEPTIC TANK ��_J" SEWER LINES r�z 'IL DISPOSAL FLDf,Z-5 L PROP. LINE A FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rrl ❑ Industrial ❑ Open Bottom 'i,Manteca Dia. of Well Excavation. f Dia. of Well Casein ADomestic/Private Gravel Pack El Tracy Type of Casing G F —4490 Specifications t��dZ.J (`l Public 1-1 Other c P Delta Depth of Grout Seal __ AP12_ .- Type of Grout ��CG-'y11G?Z- I I Irfigation - !rp dx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ y Well Destruction ❑ Well Diameter Sealing Material (top 50') N Depth Filler Material (Below 501 N TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I 1 INo 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ Na. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line # SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property 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." The applican t call or all requir / inspe ions. Complete drawing on reverse ide. Signed X y Title: ��©J Date: '2,5 YO R p ARTMENT USE ONLY Application Accepted by Date*11;5� 2Area Pit or rou Inspection by Dated Final Inspection by Date Additional Comments: � `'P- '�� o `/ - ❑ Stk 466-6781 ❑ Lodi 369-3621 L7 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 AMOUNT DUE AMOUNT REMITTED CASH11 RECEIVED BY DATE PERMIVNO. + EH 13-24(AEv.1 14 6) EH 14.26 3��/ !� 90 S�