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it APPLICATION FOR PERMIT .i SAN JOAQUIN LOCAL HEALTH DISTRICT ie 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 0�LLaJI 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. Job Address _ 1�C*�� + Al (/o`,;Sl e,cr' 'Y' Ec� City 4.4Lot Size a 7 PM ='yam � 1 /J r•J Owner's Name /__"LGi F—U%t� L7/ e'- _'Address 1 �� ' !g /�e f f/["/fna` ✓► A-A e' Phone II f i Contractor / Address � t � License No. rl Phone �C,��1-. .7r TYPE OF WELLIPUMP: NEW WELL A WELL REPLACEMENT ❑ DESTRUCTION ❑ I� PUMP INSTALLATION SYSTEM REPAIR ❑ - OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK -hUtcs"; _ SEWER LINES DISPOSAL FLD. PROP. LINE 11 FOUNDATION AGRICULTURE WELL — OTHER WELL PITS/SUMPS (I—/A.[` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial p°Open Bottom fD Manteca Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private Cl Gravel Pack Cl Tracy Type of Casing fir{ r'.e- Specifications r _ I'I Public I� CJ Other F1 Delta Depth of Grout Seal _/011 r�Type of Grout "—til lrrnlation _�Z,' Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done IJ Type of Pump /0 H.P. `S State Work Done_ E I'• I Well Destruction I ❑ Well Diameter Sealing Material (top 501 Depth Filler Material {Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION.I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.i Installation will serve: Residence— Commercial_ Other I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK I` CI T I ype/NEfg Gapacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal .i 's Distance to nearest: Well Foundation Property Line LEACHING LINE! CI No. & Length of lines Total length/size __ FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I' DepthSize Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONpS IA (�i k 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 f 1 rules and regulalions of the San Joaquin Local Health District. {� 1 1 Home owner or licensed agent's'signalure certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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 calf for all required inspections. Complete drawing on reverse side. Signed • i� ��e r�r a�,J?4 A-A!)Q,N Title: Date: •17 7 FOR DEPARTMENT USE ONLY Application Accepted by 4C. P Date Area—0---- y Pit or taut pection by.c ALJ._„� Date—"--t,Z fl(-) Final Inspection by CZ"' Dat� ��; I Additional Comments E ❑ Stk 466-6781 ❑ Lodi. 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 a Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 ' P } FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY \ INFO CASH DATE PERMIT'NO. p ♦ EH 13-24(REV. 5) "�rZ, 1 EH 14-2e