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4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON,,. CA " Telephone (209) 466-6781 { 1"PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .J - k (Complete in Triplicate) - Application 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 Na.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address CLS Pr �--3� City Lot Size PM - -- C` , AA r� Owner's Name�,M J` L C. .bulshAddress Phone Contractor Z-� �� '--Address 'ram, La-) L cense No. Phone 9 TYPE OF WELL/PUMP: NEW WELL ❑" WELL REPLACEMENT ❑ DESTRUCTION ❑ �,..- ..._...; -.. -PUMP`INSTAtiLAT10N-6 SYSTEfV4-Fi€PAIR-C r_- .,OTHER-0I--:---= .. DISTANCE TO NEAREST: SEPTIC TANK" SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL • PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' Industrial _—F. O. Open-Bottom s❑_1VIaQteca ."Dia_of�WelLExcavation- D_ia..of Weil Cosing_ _ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of"Casing Specifications fl Public f 1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation T_Approx. Depth l I Eastern Surface Seal Installed by _ I Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter'' Sealing Material {top 50') Depth ; 2r Material {Below 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION I AI RI ADDITION Ll DESTRUCTION I I (No septic-sysibm permitted it public sewer is ? available within 200 feet.) Installation will serve: Residence' Commercial Other r Number of living units: Number of bedrooms +++,,, Character of soil to a depth of 3 feet: } - Water table depth 3r SEPTIC TANK ._"BrT�pe/Mfg j C©NIC F J r=, Capacity © No. Compartments PKG. TREATMENT PLT. ❑ } / Method of Disposal c Distance.'to nearest: Well C Foundation Property.Line ._ _,_ LEACHING LINE BL-10—& Length of lines r Total length/size L �s FILTER BED ❑ Distance to nearest:- Well L:35 Foundation Property Line !Q { SEEPAGE PITS 1+1--Depth Size, )_ _ Nu i ber SUMPS `� L7 Distance to nearest: Well^' Foundation Property Line / �3-- DISPOSAL PONDS ❑ a., 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: "1 certify that in the'pdrtormance 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"tompensatiori laws of California."Contractors hiring or sub-contracting signature., certifies the following: "I certify that in the'perfor9nance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- ti n f California." The applicant call r all Co p ng on averse s'de. Signed � - � = Date: CJ FOR DEPARTMENT USE ONLY , Application Accepted by VM Date l'? � Area 6 LJ Pit or Grout Inspection by Date ' Final Inspecti n by f pDate ,� p p Additional Comments: - Ll W,&,ts ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835 5 �4 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE t INFO AMOUNT DUE I AMOUNT REMITTED CASH CK J1 RECEIVED BY / DATE PERMIT'NO. : +.EH13-24(REV.r/H 51 EH 1429