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-- APPLICATION FOR PERMIT 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 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�/ W,,.�/If G1-+T ,tM 1L1F R T� City , 7Z�C�Cn�f Lot Size _ pM Owner's Name �Iv IY-_ E H�tJ�C/T�15 I� II4 hgddress 9 W, .t`f �pj]� Phone WC, Contractor . "Address 2$ _ STSLicense No.'51Z2(-S' Phon - 713 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER E--HON IT lI.,I NJr DISTANCE TO NEAREST: SEPTIC TANK 3S SEWER LINES DISPOSAL FLD, PROP. LINE = FOUNDATION (�/ AGRICULTURE WELL OTHER WELLJ= PITS/SUMPS _ oo INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca DiT of Well_Excavation2- i/ Dia. of Well Casing _ ❑ Domestic/Private ❑ Gravel Pack O Tracy Type of Casing__ Specifications ?�' 4'90 t ('1 Public ( Other-I4dW[MJe Delta Depth of Grout Seal UJJK✓NOW r Type of Grout��' l Irrigation 12JQ Approx. Depth i I Eastern Surface Seal Installed by M1I�LrV� -; �R Repair Work Done ❑ Type of Pump H.P. State Work Done Welt Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 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 SEPTIC TANK O Type/Mfg _ _ Capacity__ No. Compartments PKG. TREATMENT PLT, O Method of Disposal > , Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size a L FILTER BED ❑ Distance to nearest: Well Foundation Property LineVoh �A SEEPAGE PITS I I Depth Sire _ Number SUMPS Ll 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. 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 applicant ust call al require inspections. Complete drawing on reverse side. Signed X r� � Title: , G�o �f _;2- ` 3 A _ __ Date: _ !j �r� FOR DEPARTMENT USE ONLY Application Accepted by .. / Date_ Area r � Pit or Grout inspection byDate Final Inspection by _ bate Additional Comments: ❑ Stk 466-6781 O Lodi 369-3621 D 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 gEMITTEDCK 4V_ INFO C SH RECEIVED DATE PERMIT NO. . EH 1324 iREV.1 es da 50 EH 14-2e , / / /for//VIYJI6 � ..