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"��'APPLICATION;FOR PERMIT ---.,... SAN JOAQUIN LOCAL HEALTH DISTRICT LNVIRONMENTAL HEALTH 1601 E. HAZELTON{AVE., STOCKTON, CA VE'M1T/SERVICES TeleliFior'iej(209) .466-6781 ' PERMIT EXPIRES 9 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. J Job Address /��/ �, 7—,4 D A E - City Aim M Lot Size ,A49es- PM Owner's Name JZdE: -a Address .Sd,!77a Phone Contractor FwD Y-, E. 4A9,0b- Address 7 .0AVW License No. Phone -37 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ \ PUMP,INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _ DISTANCE TO NEAREST;SEPTIC TANK SEWER LINES` DISPOSAL FLD. z PROP. LINE A \ . FOUNDATION `" AGRICULTURE.WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF V4IELLd PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation r l DiaJof Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of-Casing 'Specificatians{' f'l Public 1-1 Other 11 Delta Depth of Grout Seal r Type of Grout _ I I Irrigation _.-Approx. Depth l 1 Eastern Surfa`ce,Seat`In a ed by _ Repair Work Done O Type of Pump H.P:�4. ! State Work bone_ Well Destruction ❑ Well Diameter --'Sealing FMaterial (top 501 4 1 Depth ` ..Filler.Mateiial'(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 ,REPAIR/ADDITION DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation wilPserve: Residence +' Commercial/ Other ft- 'J /� �(f F� �f {�D Number of living units:,,_.___,-._ Number of bedrooms Et /SL-D d/R%� '` V Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 1 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ,�( No. & Length of lines _ l�� Total length/size /&O`VZ_` `FILTER BED ❑ Distance to nearest: Well Fo ndation t, Property Line ] �__._�....._,.. SEEPAGE PITS i)( Depth 'l-�I Size ' `f Number 1 SUMPS-�.�...- , LI --Distance to.nearest- 4-Well Foundation '` —I JC Property Line 7-V r DISPOSAL_P_ONDS—.----0�_ I hereby certify that 66ave prepared this application and that the work will be done in accordance with San Joaquin county b dinances, state laws, and rules and regulations of the San Joaquin'Local Health District. _ omLe 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 per=son in'sut manrier 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."- The applicant Aiust call for all required 'inspections. Complete drawing on reberse'side. y - Signed X Title: Gr Date: 5�—Z F R DEPARTMENT USE ONLY C� Application Accepted by Date J_F_" {[�/_P ZSArea 1 P. or Grout Inspection by Dae 7��-+" Final Inspection byi�Lf /!`/d�GCiY� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s FEE � 4 INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'No. a + EH'13-24iREV.t/14r,I 'ZYQ� :? /O�r� EH 14-28 a