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APPLICATION.FOR PERMIT 1 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)v ,, ..... 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." Job Address Z G 1�] !� SO�/OrA a CityS-� �Oo kc fi Lot Size PM. Owner's Name ' Tf Address �4,rnAc " r SS•�Z ,�,// Phone Contractore�1 'c*i G�A',TS Address (30 0 37223t-F License No. Phon y-��Lr TYPE,-OF WELL/PUMP: NEW WELL # WELL REPLACEMENT + � - �C DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ D15TANce TO NEAREST: SEPTIC TANK 2 0 0 SEWER LINES DISPOSAL FLD. aD PROP. LINE 3L FOUNDATION AGRICULTURE WELL OTHER WELL-71 O PITS/SUMPS ' 'INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ID ❑ Open Bottom ❑ Manteca Dla. of Well Excavation�A ' e Dia. of Well Casing Domestic/Private Gravel.Pack ❑ Tracy Type of Casing El Public + _ Specifications ❑ Other y ❑ Delta Depth of Grout Seal Type of Grout El Irrigation —S� T 'kms-App ox-Depth D Eastern Surface Seal installed by C: Repair Work Done ❑ Type of Pum v ,�M � R yp p — ' --- H-P•'Z- State Work Done A p Weil Destruction ❑ Well Diameter p' Sealing Material (top 50') r Depth_I��_ Filler Material (Below 501 ! TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is F Installation will/ serve:�``^Residence_f Co�rrlmercial_— bther available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: " Water table SEPTIC TANK ❑ Type/Mfg F - depth PKG. TREATMENT PLT. ❑ t ' �� Capacity No. Compartments I ' Method of Disposal Distance iotnearest: Well F undation I Property Line 1 ` l LEACHING LINE ❑ No- & Length of lines � Toial•length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Lirie I 1y SEEPAGE PITS ❑ Depth Size - SUMPS Number ❑ Distance to'nearest: Well Foundation DISPOSAL PONDS ❑ Property Line f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stat rules and regulations of the San Joaquin Local Health District. e laws, and Home owner or licensed agent's signature certifies the following: "I certify that in the i employ an performance of the work for which this permit is issued 1I shall not P Y y 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." a The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: -Lf-7 -9 ['7 T FOR DEPARTMENT USE ONLY Y { Application Accepted by >� Date Area Pit or Grout Inspection by bat / Final In pectin by 0 Date~.3 Additional Comments: -r R? ❑ Stk 466-6781 ❑ Lodi 369 3621 , D Manteca4 823-7104 Tracy 835-6385 Applicant- Return all copies to: Environmentat Health Permit/Services 1601 E. Hazelton Ave., P.O_ Box 2009, Stk., CA 95201 FEE AMOUNT.DUE AMOUNT REMITTED �,-}� INFO RECEIVED BY DATE. PERMIT'NO. V"t' + EH 13-24(REV- ��S EH 1429= i ' �� m a`� 90 - 4