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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 DATLO ISSUED UZI(Complete in Trjplicatel ��`'� � Application is heieby 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. G(Pns sn�yiS�a7.� SpA/, N0e Job Address NW ey. 69AW07- _ aLaLK City Lot Size PM Owner's Name � NC`�/ /[2 a �Xdd ef'� ""'r� X03 Ws G�W7 't- S`fl t M�NPho Contractor-5 ress ?_fzs ZS 4'• rnY4T1-!° .I icense No.31ZUIE Phone 9'ft�-13y TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER [ roS7- j5CyZj14 D S DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. tFhttie A FOUNDATION AGRICULTURE WELL OTHER WELL -P4;FS�Stlf46 M falPS w INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSIL-L ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation JN&-O(-�8844# A 4 LJ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ,5peri tGatiens wJ II aLG P it F'1 Public 1-1 Other ❑ Delta Depth of Grout Seal greet f I I Irrigation _.Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump r H.P. State Work Done _ a Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth 1 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is p available within 200 feet.) `V Installation will serve: Residence_ Commercial— Other \ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: .1 Water table depth SEPTIC TANK Ll Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ `. Method of Disposal Distance to nearest: Well Foundation Property Line 1' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to"nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size 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." A �+ The applicant mu t all for al fired inspections. Complete drawing on reverse side. Signed X Title: _-_ +E( fel A!545Z Cab Date: F R D PARTMENT USE ONLY �y / l Application Accepted by Date r V Area 1 Pit or Grout Inspection by Date Final Inspection b Date zv Additional Comments: D Stk 466-6781 ❑ Lodi 369-36211 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant Z)Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.Box 2009, Stk., CA 95201 �E FEE INFO AMOLEDUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PEFtMIT'NO. I +.EH 13-21(REV.tiny .-.l _,-. -` �1�s� ✓ J��y12..