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t APPLICATION FOR PERMIT —9- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 applicati n 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. ;7 r rl /V Job Address SW v ' or aorl Luc e & S�. City Lo r' Lot Size /70X/60 ' PM Owner's Name ew, ,wf/ Address I ��,M_�C 2 I Phone — �� Contractor ��Addr�1z0atg JF ir/ Ie Se icense leo.VZ"*v6Phone 1r6 y✓1e- _ TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 9 TBrsowA6.5 ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r?` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationDia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public ❑ Other ❑ Delta Depth of Grout Seat P Type of Grout�� I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Wg11 Dest1uction ❑ Well Diameter Sealing Material Itop 50') GUe oeo D� e eHcevq w Depth I S- Z D,r 1'OV ti`f � p T.� Filler Material (Below 50'1 � GUQ r� �' st�.J04 vr7't �lt TYPE OF SEPTIC ORK: NEW INSTALLATION l I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is C ayailable wit in 200 feet �W Installation will serve: Residence_ Co mercial Other S�Orth� r 4�hV r dY f Grp f�f 4o v R'L."fetr r-0 QYi"Ct '1_11U mber of living units: Number of be ms �{(a S�� rpv$1c W*1-9 AT tip "� Ch cter of soil to a depth of 3 feet: ater table depth SEPTIC NK ❑ Type/Mfg Capacity o. Compartments All PKG. TREA NT PLT. ❑ Me d of Disposal Distance to nearest: Well oundation Property Line LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ tante to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size _ Number SUMPS D Distance to ne st: Well Foundation Property L 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 pbrsons subject to workman's compensa- tion laws of California." The applicant t II for alAl reWetions. Complete drawing on r eese side. Signed X �'• Title: p [ I� p Date: CJS 70 F R DEPARTMENT USE ONLY Application Accepted by Date Area 9/3 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: q- � G✓ GZ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCK 0 RECEIVED BY INFO CASH DATE PERM17•NO• + EH13-241REV.tiH51 „ ,� l2 EH 1428 t V l7 �J�.11 a ��