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S E! APPLICATION FOR PERMIT SAN-JOAQUIN,LOCAL HEALTH DISTRICT 1601 E. HAZE; TON 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 application is made in compliance with SaniJoaquin 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 (6 �I i F f KPI i'1CityaE�A')-o� Lot Size PM 41 pp y aN C ^� �y 'r �, j� dao-- � fw1Sr� ti Owner's Name ��L� Jy �('�� J Address t9G oC�CJ �!�/ .I)V�z Phone Contractor Address fl //" License N /�yifl�. Phor1 ' ! TYPE OF WELL/PUMP: # NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Q 7 PUMP INSTALLATIONX SYSTEM REPAIR ❑ OTHER ❑ DISTANCE.T.0 NEAREST:,SEPTIC TANK '" ''` SEWER LINES _ DISPOSAL FLD. -�-- .PROP.,LINE FOUNDATION AGRICULTURE WELL `� ° OTHER WELL — PITS/SUMPS 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! ❑ Industrial © Open Bottom C7 Manteca Dia. of Well Excavation Dia. of Well Casing !j Domestic/Private { '❑ Gravel Pack E] Tracy Type of Casing Specifications l'l Public SSS�3*❑.Oth'er, _ fl Delta ` - ^Depth of Grout Seal Type 4f Grout _ 'I I 1 Irrigation !I .Approx. Depth I I Eastern Su ce Seal Installed by 11 Repair,Worrk Done Type of Pump �_ H.P. r . State Work Dor1e: E Well Destruction { yt� WellDiameters Sealing Material (top 50') i )A Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: , NEW INSTALLATION 1.1 REPAIR/ADDITION (.l DESTRUCTION i I (No septic system permitted if public sewer is Ij �! $ e' mailable within 200 feet.) # Installation will tserve: flesi1 ce_ Commercial___-_ Other —1 Number of living units: p Number of.bedrooms Character of soil to a depth of 3 feet: I) 'SEPTIC TANK ❑ Type/Mfg Capacity` 1 t i...,N A rE PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line LEAC,kING LINE. �. 01l�No. & Length of lines J Total lenJtll �~ FILTER BED ❑ Distance to nearest. Well Foundation 3 roperty Line .Ir SEEPAGE PITS - I I .1pepth Size Number !� T SUMPS ,. _ .❑=_ ; Distance to-nearest: Well ,.Foundation Property.Line.--, - `s. ,DISPOSAL PONDS ❑ iI 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 i 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 persons subject to workman's compensa- tion laws of California." Theapplica ust 11 forV19feqdnspections. Complete drawingo: reverse.side.Signed X Title: trYitf✓ Date: �)-yF EPAR NT SE LY i II Application Accepted by Da ate �t V , c Pit or Grout Inspection by �! Date Final lnspection'by Dat�� Additional Comments: _ I� A ❑ 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 �i INFdJtE AMOyyyUNT DUE AMOUNT REMITTED CK liECEIVED BY DATE PERMIT NO. + EH13-24fREV.iinslL5pr fJ� EH 14-25 (+ I�