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E�rIcSE(J //!J APPLICATION FOR PERMIT 7SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 1209) 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 R769 / City .1r7—J&0V Lot Size /Q 0C✓C.4ZS PM Owner's Name ld74e,,,ee, s L/r/ dI r Address Phone Contractor TF�"/.SI7 ; &Z.—Is Address STA/ License No..Ga] fJ"Y S Phone YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ } DISTANCE TO NEA SEPTIC TANK._— SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOU N AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE I TYPE OF WELL ' LEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Opeh Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private iFl_Gravel Pack. v_, 11 Tracy Ty asing Specifications I ❑ Public ❑ Other ❑ Delta Depth of Grout Type of Grout ❑ Irrigation ---Approx.,Depth O.Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump } H-P:' State Work Done F t Well Destruction ❑ Well Diameter - Sealing Material (top 60'1 _ Depth Filler Material {Below 50'1 TYPE OF SEPTIC WORK: _NEW INSTALLATION ❑ REPAIR/ADDITIONS DESTRUCTION■ (No septic systeM4 pe miffed if public sewer is 1 R available within 2210 feet.) , Installation will serve: Residence X Commercial --_€Other Number of living units: _ Number of bddfooms.4 ' Character of soil to a depth of 3 feet: -A,0CW r.� 1 Water table depth SEPTIC TANK s ■s TypetMfg Con1Cazrc/ RA Pat #4 Capacity tdb'&f No. Comp&irmnts PKG. TREATMENT PLT. ❑ a Method of Disposal I Distance to nearest: Well �'fi� Foundation�.S t Property Line �d0 LEACHING LINE ■ No. & Length of lines 5 — 90' Total length/size FILTER BED ❑Distance to nearest: Well_SOr Foundation Suez Property Line SO r SEEPAGE PITS ■ Depth 01 Size .3 o 4, Number 3 SUMPS ❑ Distance to nearest: Well I od Foundation ate` Property Line 100 DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, andD 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 taws of California." 07 The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: Date: r FOR DEPARTMENT USE ONLY Application Accepted by Date—�i 1i�� AreaV�t Q Pi or Grout Inspection bye^/ Date '!LyFinal Inspection by _�s Dat Additio al Comments: /�' 7� r�l� !.r-/lo�L1T --�I___ 6- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385Or tl� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I INFO AMOUNT DUEAMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. + EH13241REV.t/as) 0,V0 4 r 3j11�O�'$S �� EH 7428 �. ``