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� s �t 1 . r"' APPLICATION FOR PERMIT �� ,fit Q � Aid A lt t' Ldi�?s�v, N JOAQUIN LOCAL HEALTH DISTRICT ' i1tiQ� .. 41r2.rssu. ce �J� �Ic01 E. hIAZELION AVE., STOCKTON, CA PAYMENT t 1 Telephone (209) 466-6781 RECEIVED oma c I. oI� vd "ct co� 1 ` o� Mc��-, - ,.,4 - )+-:u- APERMIT EXPIRES 1 YEAR FROM DATE ISSUED r k ��4h,: (Complete in Triplicate) OCTr Application is hereby made to the San Joaquin Local Health District far a permit to construct and/or install the work herein described. This application is f made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and %$1Ro@ "t{l�tiorMphpan Joaquin I Local Health District. F k sPERMITj5ERVICE~`�)e ]'`� LotSize PM Job Address j5 1 5PM / Tg �� Owner's Name IH u"4'6 ,D Address` W 02O W K r1 i1�NW C u �'^"honef �� I / !c-u.TV Address��/4 �efta RVO�ic9se o. Phone P� Contractor TYPE OF WELL/PUMP: NEW WELL F1WELL REPLACEMENT ❑ DESTRUCTION l PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER E3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 6N FOUNDATION _ AGRICULTURE WELL - _-_OTHER_WELL- PITS/SUMPS-- b INTENDED USE TYPE OF+WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 `❑ Industrial [5-Open Bottom L1 Manteca Dia. of Well Excavation Dia. of Well Casing131, F-1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 4 ❑ Public ❑ Other iL1Delta Depth of Grout Seal Type of Grout i 1 ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done t Well Destruction [Well Dianne Sealing Material (top 50'1 Q m Depth t� - Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ _ Commercial_ OtherLn' Number of living units: Number of bedrooms r - Character of soil to a depth of 3 feet: Water table depth C, SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ' Method of Disposal PKG. TREATMENT PLT. ❑ I r Distance to nearest: Well Foundation Property Line v LEACHING LINE.: ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS ❑ Depth Size Number SUMPS _ ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f 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 k rules and regulations of the San Joaquin Local Health District. "I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature r certifies the following:"1 certify that iri the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." . ,J The appli'a must EI f r all r qu" d inspections. Complete drawing on reverse side. J —0 hal&!r Signed k Title: IP4c '�"� Date: V _ FOR EPARTIVIENPLISE ONLY // Application Accepted by i Date �i Area Pit or Grout Inspection by f Date Final Inspection by Date r Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 368-3621 ❑ 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 kaiJl] Gl/G(� G�L.0 c��z" e�e'^� a✓ CvKsv`+.<Lfr� n.a.oSar .� �a -.i Bide(_. cll. wres .,etas m_ir D,.&1.A IFEE NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT N0. EH 13-241REV.1/s5) ,.UI.J � s. {..1533 EH•14-26 ofl? - s .i ,r d 4v sf��c `