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1. APPLICATION FOR PERMIT 4. SAN 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 Lou,e;SAIE', City Lot Size 25- t&rs PM Go� � Owner's NameG Address , _ �Darcl� GL7/c�- /�i" IG Ave— Contractor iLp�� b f Addressgf�l;L License No. Phon TYPE OF WELL/PUMP: I(NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ PUMP INSTALLATIO ❑ SYSTEM REPAIR ❑ OTHEROrf DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES rel, T DISPOSAL FLD.4&E_ PROP. LINE L � J FOUNDATION __ .�Cr AGRICULTURE WELL/ OTHER WELLS PITS/SUMPS Aj INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing hn ❑ Domestic/Private ❑ Gravel Pack j$Tracy Type of Casing Specifications ❑ Public ;9 Other ❑ Delta Depth of Grout Seal Type of GroutAc �-� ❑ Irrigation ACL-Approx. Depth ❑ Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump lvl/,� H.P. State Work Done Well Destruction ❑ Well Diameter %N� Sealing Material (top 50') Depth t d 0 a Filler Material {Below 501 TYPE OF SEPTIC ORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO ❑ (No septic system permitted if public sewer is available within 200 feet.) r Installation will serve: idence I Commercial_ Other Number of living units: umber of bedrooms Character of soil to a depth of 3 fee Water table depth fI SEPTIC TANK ❑ Type/Mfg Ca act P tY No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: ell Foundation Property Line 11 LEACHING LINE ❑ No. & Lea ng lines Total length/size k FILTER BED ❑ Dista to nearest: well Foundation Property Line f I SEEPAGE PITS Depth Size Number SUMPS ❑ Distance".to nearest: well Foundation Property Line DISPOSAL P DS ❑ i I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinanpes, 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." k The applicant anus4 call for all r quired inspections. Complete drawing on revenge side. Signed ' Title: Date: FO EP SE ONLY ::; Application Accepted by �,/� DateL Area Pit or Grout Inspec y!/2 Final Inspection by pat8�/��/f/�'j• Additional Comments: V-Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 t AMOUNT REMITTED INFO -I{` CK RECEIVED BY { DATE PERMIT NO. + EH 14-24IF�EV:"'r/e 51 ,3g/� 3S �Q c,,,:, EH 1426 / -