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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/pump and the Rules and Regulations of the San Joaquin Local Health District. / T. Job Address I��/ <<� -J ��p� ls�-- City A014�1�� Lot Size PM Owner's Name ;(/zeAJ R Pd Address SQ>ne5 Phone Contractor FA.0 WD E. JJOdD Address 7 License No. /.L77L Phone 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r 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__im �i I I Irrigation —Approx. Depth I 1 Eastern Surface Seal Installed 6y Repair Work Done ❑ Type of Pump - H.P. State Work Done C^ Well Destruction ❑ Well Diameter Sealing Material (top 501 - 11 Depth Filler Mateiial (Below 50'1 \ TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted it public sewer is L available within 200 feet.) Installation will serve: Residence_ Commercial_ Other // I^) � {� Number of living units: __/__ Number of bedrooms_ E✓ /SELj� Ykw&II",('C.- \ L Character of soil to a depth of 3 feet: C1AY LAAa Water table depth SEPTIC TANK ❑ Type/Mfg w r C77 j4 Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ,QQ No. & Length of livres /00, � Total length/size 0'� � FILTER BED ❑ Distance to nearest: - Well /JrO , Foundation 440 r. Property Line 72r' SEEPAGE PITS 1 Depth Size ,7E Number r SUMPS ❑ Distance to nearest -i Well 80 Foundation X75.. Property Line 7S DISPOSAL PONDS ❑ - I hereby certify that I have prepared this application and that the work will be done in accordance with SanJoaquin 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."Contractors hiring or sub-contracting signature certifies the following: "1 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 - Title: L�t�.�l�- Date: .5--Z—gY F R DEPARTMENT USE ONLY PR Application Accepted by Date Si7_/ !,Area 1 or Grout Inspection by Da e ' Final Inspection by eZe�J Date Additional Comments: r4 arl ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 tO Tracy 835-6385 _ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r ' 1 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 9Y DATE PERMIT NO. ��//...�"ll��` IN (��} ` � EH.11211REV.riga) S"Z-9 gr✓��7 EH t41e =