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• Mme, APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 it) kin described. cribe�his 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-7-774 _,c ¢F. / �6 � , �, Job Address w L-Y L Iff City ""9 Lot Size ""�y ' PM s Owner's Name �' Q Va Addre ``'t b 9,^ -, kms, yyy +7 �' o Phone Contractor W' J f l�£ 1/f l//.Irl iAddres ��idtCbl�r CA ' elli (��`/5 �!� License No,7_763Y5 phone I6S 35 TYPE OF WELL/PUMP: NEW WELL O ---71 WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION O I SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGR ICULTUREWELL( ►"f OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI ty O In�dustria— I .. A N❑Open Bottom 03Manteca Dia. of Well Excavation _ Dia. of Well Casing O Domestic/Private) i�p Gravel Pack T _..❑_Tiracy•- Type ot'CSs�irlg"""�� pecifitiations F"1 Public Cl Other =«fl elta Depth of Grout Seal r Y.,I I Irrigation l°*q r +-4 YPe of Grout ,�, pp ox�Depth t I astgrn Surace Seal Installed by W Al r��jt lc Repair Work Done L_7/Type of Pump H.P. State Work Done Well Destruc ion E Well Dia to � Sealing Material(top 50') ' �7 l (7'0 p ?� Depth C. 1 Filler Material t8elow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPAIR/ADDITION I I DESTRUCTION I I fNo septic system permitted if public sewer is !� available within 200 feet.) Installation will serve: Residence— Commercial— Other • Number of living units: Number of bedrooms ^ ;''� �'� q %vpk \ Character of soil to a depth of 3 feet:_ 'v °Water table depth t SEPTIC TANK ❑ Type/Mf w++s + g CapacityNo. Compartmenis PKG. TREATMENT PLT.❑ � Method of Disposal Distance to nearest: Well Foundation + *"'yt'1Property Line�t+ � i LEACHING LINE ❑ No. &Length of lines .� Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line.` SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Pro DISPOSAL PONDS ❑ party Line 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 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:"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 applicjt7 c Arr call required inspections. Complete drawing onaverse side. 5zmco Signed X Yl-� (It., Title: C�.,�fo • �'�„/ Date: FOR DEPARTMENT U E ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection b Oate Additional Comments: ❑ Stk 466-6781 O Lodi 369-3621 O 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 K INFO /H'y RECEIVED 6Y DATE PERMIT'NO. + EH 13-24{REV.iixsi EH 1426