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1� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT _ 1601 E. HAZELTON 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/Dump and the Rules and Regulations of the San Joaquin Local Health Districts. S Job Address ��% C Y/5 M'90V )?C�, City ypC Lot Size PM AC04,re2 el C.9. Owner's Name A�/ .1fh 45 h 196/ Address Yg Z e Sh r_Y WOOlf CT. Phone Contractor 4,4r/ 124!97Q11V Address `dD-T 04 "' u MOII(y rOLicense No. `/Yy 89' Phone _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE -- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done V, Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 64 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) w Installation will serve: Residence L Commercial_ Other. -,/Jy Number of Irving units: 1._ Number of bedrooms 3 /� --'q /r AS ��/u� � Character of soil to a depth of 3 feet: L/a h T L orYWater table depth SEPTIC TANK JZ Type/Mfg .— CysT Capacity No. Compartments 2- r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well o Foundation Property Line 0_d9 a•s LEACHING LINE jL No. & Length of lines A – F0 Total length/size 14e, FILTER BED ❑ Distance to nearest: Well 130 Foundation //� Property Line 6� �. SEEPAGE PITS ❑ Depth Size y"r/or If" Number 2 SUMPS IX Distance to nearest: Well 9'9 Foundation go Property Line rr 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 persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X f7., .SG Title: Date: 5.�/C–�� OR ARTMENT USE ONLY Application Accepted by / Date s Area a. Pit or Grout Inspection by Date Final Inspection by 4t Date___/4t / i Additional Comments: 52� '/ `el �– �� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 7104 ❑ Tracy 835-6385 ly r, Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK N RECEIVED BY DATE jPERMIT,,NoINFO r EN t}21(REV.ries) � –7c) �p EN W25