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APPLICATION FOR PERMIT SAN OAQUIN LOCAL HEALTH DISTRICT 1601 L&ELTON AtE, STOCKTON, CA Tdlephone (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 J A6�� C r Ff C € City Since"4Lot Size PM J Owner's Name Vr t'it0 C,4 L `o 00—15� Address oi� 7� ' r 7/ twor.'m C'* P.— Contractor ��••I`,!! � _�g��, �x�r_ e � Pho Contracto _ Addres �09 � /� 3 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHERC1�<Qy1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL ITSISUMPS INTENDED USE1 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI Irtt<lastriak ,pfli� Open Bottom ❑ Manteca Dia. of Well Excavation p Dia of Well Casing O .. Domestic/Private Gravel Pack El Tracy Type of Casing �# O / Sp cificationk / rr El Public ❑ Other 1:1Delta Depth of Grout Seal N Ty of Groi1(+ ` O ❑ Irrigation _-__-Approx. Depth ❑ Eastern Surface Seal Installed by A, / LC"/ L1)CA OL Sp Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material {top 50'1 Depth Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system p rmitted if public sewer is available within 200 eet.) Installation will serve: Residence_ Commercial Other V Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table d pth �I SEPTIC TANK ❑ Type/Mfg Capacity No. Compart nts PKG. TREATMENT PLT. ❑ Method of Di osal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 11 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS L] Depth Size Number SUMPS C7 Distance to nearest: Well u� , i Property Line DISPOSAL PONDS ❑ w I hereby certify that I have prepared this application and that the work will be one in a dance with San Jo uin county ordinances, state laws, an 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 pe rmance of the w 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." ntractor'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 sh mploy persons subject to workman's compensa- tion laws of California." Thea t Signed X -ti+ Title: jZvr.Ed1.pC fS' Date: AAS cA4 ONLY Application Accepted b L" Area Pit or Grout Inspection by Date 1-3— Final Inspection by Date Additional Comments 466-6781 1 Manteca 823-7104 0 Applicant- Return all copies to: Environments a rvices 1 E. Hazelton Ave., P.O. Stk 1FEE INFO AMOUNT DUE AMOUNT REMITTED K k I RECEIVED 6Y ATE PERM^I�T''NO. + EH 3-24 1EH 1428 I tin 51 © 104/,-7