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ry APPLICATION FOR PERMIT Pty'" SAN JOAQUIN LOCAL HEALTH DISTRICT 4' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (Con'plete 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 Address2 7 City 4 k Fpd Lot Size PM 2 Owner's Name + 1 �/'� t `1 Address �n Phone G Contractor J,J.L. GdtO,SS d-,Sarfr Address q 7 1 5 License No.-Elln2 5- Phone I Vd 2 2 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ , � PUMP INSTALLATION �Bl/ - SYSTEM REPAIR 171OTHER ❑ ` DISTANCE TO NEAREST:.SEPTIC TANK "i SEWER LINES "� DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r, ❑ Industria!- — pen Bottom-----G-Manteca *---Dia.-of Well-Excavation- "" " ''Dia. of 1N bell Casing'" amestic/Private Y❑ Grave} Pack ❑ Tracy Type of Casing Teel- Specifications p �. a f 1`Public ❑ Other D Delta Depth of Grout Seal ��0 Type of Grout� 4_ I I Irrigation 32f Approx. Depth I I Eastern Surface Seal Installed by ' L C2 _ Repair Work Done ❑ Type of Pump ts"i5 H.P. S State Work Done _ i Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is j F` available within 200 feet.) Installation will serve: Residence_ Commercial_ Other rg,Num6er of living um Number of bedrooms- Yom'"� � .` 2C 1- 0 of soil to a depth of 3 feet: Water table dept \h \VC i SEPTIC TANK ❑ Type/Mfg; Capacity partments PKG,,,TREATMENT PLT. ❑ ' Method of Disposal 3k ` Distance to nearest: Well Foun Property Line LEACHING LINE ❑ No. & Length of lines Total lengt r FILTER BED Q Distance to sI: Well Foundation Property Line r t i SEEPAGE PITS I I Depth Size Number SUMPS D Distance to nearest: well Foundation Property Line t DISPOSAL PONDS ❑ i 1 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 a rules and regulations of the San Joaquin Local Health Diltrict. 1 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 f 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." } ,Ka } The applicant must call for all required inspections. Complete drawing on reverpe side. t,J 1 Signed X. b "YW,94 4 Title: 44,14 Date: R DEPARTMENT USE ONLY ( Applicati ccepted by- ��"� J� A Date ` Area I -Pit o` rout spection b Data mal Inspection byP1 0 14 � /1�C�c Date 1 % Additions Comments: 0 Silk 466-6781 O Lodi 369-3621 C) Manteca 823-7104 ❑ Tracy 835-6385. Applicant Return all copies to: Environmental'Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE \( INFO CK AMOUNT DUE '--AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. 9a! //-?Z.EH 13.24{REV.t/x5) / p + i EH 1428 ! Q�-� P �>S �V/ !U J