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-• APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. Job Address -6e,ZC0f% . 4-]O N- Mz o S�feet- City mcd''1�,•e rLo_t Size PM Owner's Name�e �` �� CSP"y1 Address cJZS �• t�c� �x�2�. }kzrT�Mdr CA Phone -SR 2'VZ-41 A32-SS 81va. Slt.g Contractor ate C�C�O S�eMS Addess TTefYty,+i License No.CEG1Z64— Phone 1s,-Ls i-t c) TYPE OF WELL/PUMP: NEW WELL K 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 .1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 10" Dia. of Well Casing )<�De""stiweiLP� Gravel Pack I I Tracy Type of Casing Sch A0 PV C Specifications Cl Public Cl Other 1 1 Delta Depth of Grout Seal —I///5 1 Type of Grout Ll Irrigation ---Approx. Depth I7 ��Eastern Surface Seal Installed by ��`� .� Repair Work Done I I Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter 4' Sealing Material (top 501 Depth ' 4'0 Feed Filler Material (Below 501 YPE OF SEPTIC WORK: NEW INSTALLATION 71 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installs will serve: Residence_ Commercial Other Number of livr nits: Number of bedrooms Character of soil to a th of 3 feet: --.—Water table depth SEPTIC TANK n Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. 1'. / Method of Disposal Distance to nearest. Well Foundation Property Line LEACHING LINE I] No. & Length of lines _ Total length/size FILTER BED i- Distance to nearest: Well undation Property Line SEEPAGE PI Depth Size _ Number SUMP 1 . Distance to nearest: Well Foundation_. __ Property Line D OSALPONDS is 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 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 us I for r uir ions. plete drawing on reverse side. / Or Signed XTitle: fY12112Sf� T Q)i_��W�S � Date: 1) L4( ------- R DEP T T USE ONLY �`` ��JCL Application Accepted by _ _,-_ .__. Date A Pit or Grout Inspe, ro Date�� Final Inspection by - �� Date �/ _ 7'Z V L , Additional Commer>ts/ r b r/ (-I Stk 466-6781 f.J Lodi 369-3621 C] Manteca 8 _l Tracy 35Gd85 Applicant - Return all copies to: Environmental Health Permit/Services 1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY `` DATE PERMIT NO. EH 13-24(REV n�„ 37 •�� J- ��Q IO � 1�� EH 14-28 J