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.. ?c all APPLICATION FOR PERMIT toe SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES .1YEAR FROM DATE ISSUED F (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 _ ti City l Lot Size gr PM Owner's Name _L .�G�. ' IN Address 5 G6! 4 ' — Phone r 1 Contractor's Name I&C [7 ' � License No. � � Phone TYPE OF WELL/PUMP: NEW WELL ❑ 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 SPECIFICATIONSf I ❑ Industrial Q Open Bottom ❑ Manteca Dia. of Well Excavation a I - Dia. of Well Casing I Domestic/Private Gravel Pack ❑ Tracy Type of Casing 5 F G� N�, ' , .% __Q.Yuhlic- _ '""`-.'� i -z.,Spe c+ficat�ions D Dther�. ",k.. .`_-L�-Delta -- D of-rr�u SAa6'�. CS Type.ofrout C ❑ irrigations—Approx. Depth ,❑ Eastern Surface Seal Installed by '� ! Repair Work Done , Type of Pump.se_ H.P. � � r r State Work Done lyed e �0- pr e Well Destruction Well Diameter f __ Seating Material atop 50'1 ee b'#Z ig 4 f� < Depth f�(�_ Filler Material {Below 501 TYPE OF SEPTIC WORE NEW INSTALLATION ❑ REPAIR/ADDITION ❑= DESTRUCTION ❑ (No septic system permitted if public sewer is ` available within 200 feet.! Installation will serve: Residence Commercial— Other A�_• Number of living unifs': Number of bedrooms "� r Character of soil to akdepth of 3 feet: 11 Water table depth SEPTIC TANK 0❑ Type/Mfg#'i Capacity!',"� No. Compartments ' PKG. TREATMENT PLT;-,CI I s le, �y Method of Disposal i Distance to.nearest: ""'""'Well" "r 'r' Foundation / Property Line LEACHING LINE ❑-,-.No. & Length of lines' "- l x ! Y Total length/size FILTER BED ❑ Distance t. nearest: Well -F In Foundation �^ r Property Line SEEPAGE PITS ❑ Depth Size f - Number SUMPS ❑ Distance to nearest:____Weli l'"Pfoundation r n Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done fn accordance with San'Joaqutn county ordinances, state laws, and rules and regulations of the Sari Joaquin Local Healtht District. Home owner or licensed agenYs'signature certifies t e fdllowin`• "I ce ' 4`� �'' employ an 6 rrrfq �-t in the•performance of the work for which this permit is issued, I shaft not p y y person in such rrianner as to become subject to workman's compensetion 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 per'rnti Js issued,I shall employ persons subject to workman's compenSa- tion laws of California." The applica ust If for all'required ctio Com a drawing on reverse side. Jj4 A Signed / ff 4 !: Title: Date: �r t Vo T FOR DEPARTMENT USE ONLY., i I Application Accept by Date Area✓ i I Pit or ro Inspection by Date r'^ final Inspection by Dale&:2 6 Additional Comments:i A ❑ Sik 466-6781 C7 Lodi 369-313321 ❑ Manteca 823-7104 ❑ Tracy 835-6385 �— Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box2009,Stk.-?CA 95201 r FEE AMOUNTDUE AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE PERMIT-NO.' + EH 13241REV.10!831 EH 1426