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�f 7 APPLICATION FOR PERMIT 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.TMs application is made in compliance with San Joaquin County 00rdiripince No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 7/JS Job Address s6v:c�i -�y/ r sr .07 City' Lot Size0.*'. PIM � I J " "Owner's Name Address XC®e� Phone Contractor Cr✓ AddressLicense N �,G��/ Phone/ TYPE OF WELL/PUMP: NEW WELL 12L WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION A SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1aA �- SEWER LINES baa DISPOSAL FLD. PROP. LINE ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ^t r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS }�J r/ I ❑ Industrial El Open Bottom lam.Manteca Dia. of Well Excavation 2 ! Dia. of Well Casing O [K Domestic/Private'-te'�-I 4 flk.Gravel Pack El Tracy Type of Casing C exl ,Specifications F ❑ Public Other :-,e -Z 1-1DeltaDepth of Grout Seal � - Type of Grou ❑ Irrigation .;" Approx. Depth ❑ Eastern Su ace Seal Installed by .1! n/ I �! Repair Work Done ❑ Type of Pump H.P. / 2— State Work Done a 4 Well Destruction ❑ Well Diameter � Sealing Material (top 50_) s Depth Filler Material (Below 5011 TYPE OF SEPTIC WORK: NEW INSTALLATION)& REPAIR/ADDITION ❑ DESTRUCTION ❑ (No'septic system permitted if public sewer is o +` x available within 200 feet.) Installation will serve: esidence Commercial , Other , Number of Irving units: Number of bedrooms _ t � "� ►�' '� g Character of soil to a depth of 3AC t �" f Water table depth { SEPTIC TANK ❑ Type/Mfg i Capaci G.4-L`'^i 9. Compartments r PKG. TREATMENT PLT. ❑ ' I Method.af Disposah g'd r Y Property Line�.� i; Distance to nearest: . II oundation �- LEACHING LINE ❑ No. & Length of lines 6 Total length/size FILTER BED ❑ Distance ton st: Welle!fW _ dation 1513 r Property Line SEEPAGE PITS ❑: th Size Number y SUMPS Distance to nearest: Well Foundation roperty Line DISPOSAL PO ❑ hereby certify that I have prepared this application and that the work will be done in accordance with Sane aquin 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'i 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 must call for all required inspections. Complete drawing on reverse side. F Signed Title: Dater T FOR DEPARTMENT USE ONLY t Application Accepted by i Date d/�-� Area Pit or Grout Inspection by `r Date 5' inal Inspection by Date -7 Additional Comments: II ; . ❑ Stk 466-6761 ❑ Lodi 369.3621 Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant-.Return all copies'to: Environmental lftaPen'Thit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIVNO. 9–+ EH-13-24-IREV.i/s51 �- . ., �. - _ _-�....,.._ . .�.-._....-...a...�...... . —s,..,...• __. -v - lo—Sw� /� EH 14-Ze