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` I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I 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. o 4 Job Address Ufa y Rnn 0 (E)e PA_ city Lot Size PM Owner's Name WE 27,©. Address s �� cz] �.6 0,S,/ 13/ Phone Contractor's Name 1411�� LGc2 License No. y 7�6 z Phone / TYPE OF WEL-L/PUMP. --------NEW-WELL—ID WELL--RCPLAGEMENT—O——DESTRUCTION-(E -, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia, of Well Casing e ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other % 171Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump{ State Work Done Well Destruction ❑ Well Diameter' Sealing Material /top 501 DepthFillewMaterial-(•Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic sstem Permitted if public sewer is i t available within 200 feet) Number of living units:�_ Number of bedrooms Character of soil to a depth of 3 feet: �_n L3 L� ""` _ Water table'depth SEPTIC TANK ❑ Type/Mfg P .�i Capacity._-, .v[rrs No. Compartm_4As PKG. TREATMENT PLT. ❑ d CfUM}�ur,y��1 w�Z,Z•- �._.h fc�=-.•a:Method of Disposal Distance to nearest: Well Foundation^- y Property Line E ' J _ Total len th/size Fac LEACHING LINE No. & Length of lines { �a — g FILTER BED '❑ Distance to nearest: - Well Foundation Property Line I SEEPAGE PITS ❑ Depth Size 14-umber _- (16 SUMPS< ❑ Distance to nearest: Well -Foundation Property Line r i DISPOSAL PONDS ❑ 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. ^ - f 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 Ij employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring br 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 uired inspections. Complete drawing on reverse side' ' Signed 3Ce / Title: ` �r b�L/ ' Date: I FOR DEPA TMENT USE ONLY Application Accepted by © ` ' �� date 5 J 'Area f , Pit or Grout Inspection by .Date Final Inspection by ,if % Date �� T Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3693621 EI Manteca 823-7104 ❑ Tracy 835-6385' Applicant- Return-all-copies to:.Eri`vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK INFO ;AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 6Y / DATE PERMIT`NO. + EH 13-24[REV.101931 �' ®4 �., V -PS 4 6� EH 1428 J��/