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I APPLICATION FOR PERMIT 11 y SAN JOAQUIN LOCAL HEALTH DISTRICT V 1601 E. HAZEL TON AVE., STOCKTON, CA BAR 21989 Telephone (2091466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUEDNMEN`AL HEALTH I! (Complete in Triplicate) ENvtR0Nl r SERVICES Application is hereby made to thed'.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. i �,lti r �7••� r Job Address City - Lot Size 16 l- PM ; or-�rc67 3v4-- 9� Owner's Name i� 77- Address a, Ph Contractor (�Aiu&)MC dress S. k 20 Tense No32_/2.K- Phone 4 TYPE OF WELL/PUMP: NEW WELL 7, WELL REP ACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ .DISTANCE TO NEAREST: SEPT1i IC TANK SEWER:LINES DISPOSAL FLD.raot PROP. LINE / FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAJ�ON5 [I Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation 2 Dia. of Well Casing Domestic/Private Gravel Pack Cl Tracy Type of Casing Pvc Specifications i F7 Public l-1 Other ..7-4-Delta Depth of Grout Seal G Type of Grout I 1 Irrigation le_-0_4prox. Depth I I Eastern Surface Seal Installed by 4't- - _ q Repair Work Done ❑ Type of Pump H.P. State Work Done X1'1 Well Destruction ❑ Well Diameter Sealing Material Itop 501 ,I Depth Filler Material (Below 50`) — TYPE OF SEPTIC WORK: NEW INSTALLATION {1 REPAIR/ADDITION i I DESTRUCTION I 1 (No septic system permitted if public sewer is ;i available within 200 feet.) ij installation will serve: Residence— Commercial_ Other r Number of living units: Number of bedrooms d Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLElT. 11 Method of Disposal Distance to nearest: Well Foundation - Property Line i� LEACHING LINE ❑ Nb. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line al ,i SEEPAGE PITS 11 Depth Size Number ,I i SUMPS 0 `Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Lf _ - '" " �4 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 Di§trict. Home owner or licensed agent's signature certifies the fallowing: "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 c7811 ify 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 applica ust I f req red inspections. Complete drawing on r v rse side Signed Title: Date: FORADEPARTMENT USE _ LY Q Applic n Accepted by I Date ��d _p Area d ly- CJ o/ --� Date Jr �4- F _ ` Final Inspection by Date P. or Grout I pection by . _I f R - IF Ad 'kfi o n aj Xomments: On ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 5-6385 t�l� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOiJhT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMiT'NO. INFO CASH II ' +.EH 43-24 1REV.1/n 51 EH 14-26 1� II "J