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4a APPLICATION FOR PERMIT ��C �� SAN .�OAQUIN LOCAL HEALTH DISTRICT �� 7, 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 13 � W 1 p C7 City C Lot Size 3 nC►e_197'r PM Owner's Name A, k_ 10 r� s/`b C 1� 3?/J Address P- 0 9 0 k I I c' S1_0C6"A) QS201 Phone 2 D - Contractor Si GtJ]1y2.j� Address Aw /2/U�/2 'f--S�S,1License No. jttl Phona TYPE OF WELL/PUMP: NEW WELL;K WELL REPLACEMENT ❑ DESTRUCTION ❑ " PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -55X'��-f�DISPOSAL FLO. PROP. LINE ' I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS •DC7 Industrial 1�7�� ❑ Open Bottom ❑ Manteca Dia. of Wel{ Excavation �' � Dia. of Well Casing /❑1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 49z0J,LjCSf Specifications M Public IrOther XI Delta Depth of Grout Seal Type of Grout I I Irrigation —..Approx. Depth L I Eastern Surface Seal Installed by ? _ Repair Work Done ❑ Type of Pump X(4 I H.P. State Work Done Well Destruction 171 Well Diamete, F� `/Z�r Sealing Material (top 50'1 Depth A5'/ — !5:+) Filler Material laalow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I l DESTRUCTION ( I (No septic system permitted if public sewer is availabl $ 1 / Installation will serve: Residence_ Commercial_ Other a Ft• t-:� " !1= >t Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: WaterI1leltable depth LJQd SEPTIC TANK Type/Mfg Capacity No. PO4rt&nts1 PKG. TREATMENT PLT. ❑ Method of Disposal - Distance to nearest: Well Foundation Propeti l irt> ;-EL.r��LT+{ L LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS # I Depth Size Number i SUMPS (_l 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." The applicant ,,must call for all re u' d inspections. Complete drawing on reverse side. Signed X (� ad Title: d 4 % Date: 41PR 7t FO DEPAR USE ONLY f Application Accepted by Date ! ~� Area Pit or Grout Inspection by _ Date _Ij1 Final Inspection by Date Additional Comments: G ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 EJ Tracy 835-6385 Applicant- Return at]copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE # i INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. +.EH13-24 IREV. /x 51 ('� - �/' ,,,�• ,.y^ EH 1426