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APPLICATION FOR PERMIT 1° SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. i-IAZELTON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ,u!FAs,'i', t9.�� /1 f lif ti+ th�4J?f (Complete in Triplicate) ,+ `+�! Application is hereby made to the San Joaquin Local Wealth District for a permit to construct and/or install the work herein descfil�etl+{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 w(i'Sjpnp;Joaquin Local Health District. Job Address City Es ry{fJ4 Lot Size PM / r f Owner's Name �,LL � _I Address 3,M IV,2`CAI Phone Contractor r : -Z- L(-Address�� url-. i.. License No V Phone �D— TYPE OF WELL/PUMP: NEW WELL (71 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM R)EPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES dd DISPOSAL FLD.�� PROP. LINE FOUNDATION AGRICULTURE WELLkK- OTHER WELL 1 ITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONP A ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excava ,,nDia. of Well Casing j$( Domestic/Private )(Gravel Pack ❑ Tracy Type of Casing �/� � , Specifications �J, ('1 Public n Othey,� C] Delta Depth of Grout Seal AN) � Type pf/Grout . I I Irrigation _., pl r Depth I 1 Eastern Surface Seal Installed by��l ��1L1 1 /�L11i1 - /��_ _ y Repair Work Done ❑ Type of Pump H.P. State Work Done — ^ Well Destruction ❑ Well Diameter Sealing Material (top 50') {f t( Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it 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 t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal CIO Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I Depth Size Number SOMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS E1:, T � RI 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must callforall requuiiirre inspections. Complete drawing on averse side. /�J J Signed ��J //d .l�fLJ� T Title: j-t`I IA Date:, r� DEPARTMENT USE ONLY Application Accepted by Date Area 9�f / Pito roti inspection b Date�� 7L �Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ 6efri 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 45201 INFO EEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. ♦ EH13-24IflEY.tin5Y 40 ��/D� CP?I EH 14-28