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Y APPLICATION FOR PERMIT - 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 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. r 1� �! AA C �,exy PM Job Address -�7 J; ' G Gores w City �I�C Lot Size_44/>r C�'1eGI��+I 8r Ga'9G A"q. /ev 9Z) '�y1��.SeMi dI LJI7pr �c� Owner's Name h Address p� Z Zrle Phone 9yy zZ / Contractor 19700C 66W-S411,'*D';I Address Ltlts JP669 License No, TYPE OF WELL/PUMP: NEW WELL &&)& WELL REPLACEMENT ❑ LDESTRUCTt( N_ PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t.—. A4A,e�1,4,-g tuiar�i.r,. FOUNDATION AGRICULTURE WELL `' OTHER WELL PITS/SUMPS 16-0� ' INTENDER USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 3 t Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack XTracy Type of Casing Specifications I I'1 PublicO;Approx, her 0 Delta Depth of Grout Seal �� Type of Grout /?G',e. — I 1 lrrigation Depth ( I Eastern *.w�Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. ? State Work Done_ f Well Destruction ED Well Diameter -3 Sealing Material (top 50') 4VIV 14400 .7ath SrJ �-t Filler Material (Below 50'1 - TYP,E OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION 1.1 'DESTRUCTION l I (No septic system permitted if public sewer is r available within 200 feet.) Installation will serve: Residence Commercial— Other i I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: r 'i Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ` _ C LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well r Foundation Property Line SEEPAGE PITS I I Depth Size i Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 parsons subject to workman's compensa- tion laws of California." , Theapplicant muu calllr for all req/ui�redd inspections. Complete drawing on reverse side. Signed X (/��G._ /�/ Title: I�SSdI/G7� Cr�alv ritrCr Date: g �� 7MARTMENT SE ON Ly cs; w - � Application Accepted by Date Area Pit or Grout Inspection by, ti Date �"Q Final inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy-835-6385 - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant p , FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. `- INFO 4 + EH 13-24 1 R EY.1/n 51 � O V l U7 l (� t` �Ii i4 EH 7429 t