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APPLICATION FOR PERMITT SAN JOAQUIN LOCAL-HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED 1 (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 Ryles and Regulations of the San Joaquin Local Health District. Job Address "' 7:3 /.la dj� >4 It / 14C Ci BOK TO AI Lot Size PM Owner's Name ` Address 4:Z 0/– 'k' Mq pe I p L9 s I ;F)-., 47 f/__ -9 9 la Phone �QCQr2N/�11I S ,�, Addresso��a YV 1 C D X D � 7 ontrac or License No.Y_49 Phone 3� Q TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ _ _ _PUMP INSTALLATION _ SYSTEM REPAIR ❑ _ OTHER ❑ _ r ,DISTANCE TO NEAREST: SEPTIC TANK IO �� SEWER LINES DISPOSAL FLD. PROP. LINE I' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC ATI S ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatkin J745 Dia. of Well Casing Domestic/Private s Gravel Pack ❑ Tracy Type'of Casing Specifications �y ❑ Public ❑ Other ❑ Delta' k }Depth of Grout Seal r Ag T (L , YP of rout � C�P0Tr ❑ Irrigation 2�2u Approx. Depth ❑ Easiarn SurFace Seal Installed by 0 ll� � ATE TE ,- / $ Repair Work Done ❑ Type of Pump L1.R H.P. State Work Done LN�T/f.l.�. Well Destruction ❑ Well Diameter Sealing Material,itop 50'1' t _ _ _ _ Depth Filler Material (Below 50') 6- TYPE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) J Installation will serve: Residence_ Commercial_ Other LV Number of living units: Number of bedrooms – -- Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PL-T. ❑ Method of Disposal € Distance to nearest: Well Foundation Property Line , LEACHING LINE ❑ No. & Length of lines g Total length/size � FILTER BED ❑ Distance to nearest: Well Foundation Property Line 3 F `SEEPAGE PITS Y ❑ Depth Size Number ,SUMPS 1, . ❑ Distance to nearest: :,Well. - ^Foundation Property Line f DISPOSAL PONDS'r ❑ ! ! he certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and k rules and'regulations of the San Joaquin Local Health District. - __1 Home owner or licensed agerit's signature certifies the following: "I certify that in the performance of the work for whichfthis permit:is issued, I shall not fi 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 Wormancerof the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." f The applicant st-call f r all re uired inspections. Complete drawing'on- v rse s% ' I Signed Title: �-(6 Al-rRA d- 7a` .-- Date: �S t r -` �. FO PART ENT USE O LY f . .' Application Accepted by Date � - I `" Area Pito Grout I pection by ate _ Final Inspection by' !pate Additional Comments: r ❑ Stk 4W6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385,. Applicant-Retum all copies to: Environmental Health Permit/Services,1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED, CK RECEIVED BY DATE. INFO -- 'GASH ,}. ,PERMIT'NO. + EH 13241REV.f/a51 �: - - ,�'t .� [1 5+ p—•� EH 1426 O