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0 • T�AY�`va APPLICATION FOR PERMIT • ' ; LEC1✓j USAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED L IENV1CNM-I,\Ji,,L HE�LTu (Complete in Triplicate) A)2/l AA' 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.54 Job Address / " 1 //iJ City / Gi7 Lot Size PM / .3`9 �Owner's Name / .!d /Q ,6- Cr Address �C � � �6G po9wA9 Z4U�re.ac� 1Jq�i�!/�. .��c_ x49604/ &0 o Contractor Address 2CM11v�r, elel License No.s'��5z7 Phone _Z��—/�Q3 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION El SYSTEM REPAIR El OTHER El DISTANCETO NEAREST: SEPTIC TANK A SEWER LINES >`5"f DISPOSAL FLDN_- PROP. LINE �� l FOUNDATION /'11..x' AGRICULTURE WELL�h- OTHER WELL 900 ' PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 0 Dia. of Well Casing ❑ Domestic/Private IK Gravel Pack ❑ Tracy Type of Casing ''tee/ Specifications i FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of GroutARd e 47_L Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 4� Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments v� PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 0 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS Lt Distance to nearest: Well Foundation Property Line 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. —e 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 applic�nustll for all re 'redlinspections. Complete drawing on reverse side. Signed Xr�� (.t�t2zC,(� Title: �� P Date: t OR DEPARTMENT USE ONLY i Application Accepted by Date Area Pit or rout nspection by i � date�� Final Inspection by Date Additional Comments: O'1loJ J! ❑ Stk 466-6781 ❑ Lodi 69-3621 f 7 ❑ 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 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY INFO CASH A DATE PERMIT'NO. + EH 13-24(REV.sins) Vd 1' tv EH 14-28 VV ` `