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VT - - i y _4v APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT j 3 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1 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. •. 5 Job Address 1ii.iJf`tL7Q,.= 1�0 City Lot Size PM f Owner's Name L_ ERDMC- Address Phone�g Contract /ur �r�`Q Tf Address 1 32. �t t3�l`a f1A Suye� License No ria 11�t TYPE OF WELL./PUMP: .r . NEW WELL[ WELL REPLACEMENT ❑ DE IM s PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ .�� DISTANCE TO NEAREST: SEPTIC TANK &3V ___- SEWER LINES i-1 i DISP PROP.kILIN�=Ik_ FOUNDATION AGRICULTURE WELL OTHE ' LL L,'�-,SUMPS I_-- - —INTENDED USE =TYPE-OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO �nA 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 0yQ1a-o Casing 21a 5 4- ❑ Domestic/Pnvate .Gravel Pack ❑ Tracy Type of Casing loic ��1R _�-, `'gom irons 09-9.1 PA-E O I 1 Public ❑ Other Ll Delta Depth of Grout Seal 'SS F` .. Type of Grouter er r, I I Irrigation __Approx. Depth I. I Eastern Surface Seal Installed by Co`,`�Ar Repair Work Done ❑ Type of Pump H.P. State Work Done_ F Well Destruction ❑ Well Diameter Sealing Material {top 50 I Depth Filler Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIRIADDITION I DESTRUCTION t I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t k PKG. TREATMENT PLT. ID Method of Disposal BI Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r t SEEPAGE PITS I I Depth Size Number SUMPS i_1 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 fol wh_ich this permit is issued, I shall h n 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." ,The ust call f II u' inspections. Complete drawing on re rse side. ) Si nad X Title: 'r'��E,yyi-V�J _ Date: 11 —11 FOR DEPARTMENT USE ONLY Application Accepted by Date �l�s�` �� Area Pit or Grout inspection by Date Final Inspection by A4 ra& Date �. Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Enviroentat Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 � oh -Lf— '70144,2,_L•..._ VEE INFO AMOUNT DUE AMOUNT REMITTED CK itj RECEIVED BY DATE PERMIT'NO. a EH13-24(REV.1/9 5) EH 14-28