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4�1 APPLICATION F[?R PERMIT SAN JOA( UIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED kk (Complete in Triplicate) Application is hereby made to the San Uoaquin 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. T Job Address g �C' V City 5 Lot Size/ PM —StO kE_p Address Phone Owner's Name � }�_ ,�•.•_ �* Contractor��E_,P� W h;t=�NL_L -Address � License No. 3Vpol Phone TYPE OF WELL/PUMP:. ;i_.'� NEW WELL'❑""'; WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER 1-1 ' DISTANCE TO NEAREST:'_SEPTIC TANK SEWER LINES r DISPOSAL FLD. — PROP. LINE ' FOUNDATION #AGRICULTURE WELL l OTHER WELL PITS/SUMPS j ._ INTENDED USE TYPE-OF"WELL.-- � PROBLEMAREA CONSTRUCTION SPECIFICATIONS + I C LlIndustrial �3 0.Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Wel! Casing ❑ Domestic/Private E] Gravel Pack ❑ Tracy Type of Casing Specifications I .. ❑+Public ❑ Others ❑ Delta _ Depth of Grout Seal Type of Grout .,� ❑ Irrigation � Aboroz. Depth ❑ Eastern-- Surface.Seal Installed by i Repair Work Done ❑ Type of Pump?. _ N.P. { State Work Done { Well Destruction } D. Well Diameter ' 1 Sealing•Material (top a0') r 1: L �} _1 f Depth F 4 ' -J. Filler-Material-1Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other } _a_'--_ Number of living u�iits:' Number of bedrooms Character of soil to a depth of 3 feet: �b _ Water table depth SEPTIC TANK l -ype/,Mfg-- a 'city D-QQ No. Compartments L ` Method of Dis osa! ' PKG. TREATMENT PLT:❑ 1 .. r " Distance to nearest: Well 5a Foundation Property Line LEACHING LINE U.-No. & Length of lines T Total length/size FILTER BED ElDistanc a to nearest: Well Foundation Property Line 5 I SEEPAGE PITS v E-1390004— "'§a6 t a Number SUMPS / to nearest: V11 ell a t Foundation�,� erty PropLine + i t DISPOSAL PONDS El1 vLX f S ' 1 hereby certify that I have prepared this application.and that the work will be done in accordance witif San Joaquin county ordinances, state laws, and f rules and regulations of the San Joaquin Local Health District. 1 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 xemploy,any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature cert' as theffollowving: '9 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- �c tion la f California." q �"'►�r� Th applican. ust II fora requ din ctions o e ete drawing on erre si e. Signed — Title: Date: f I FOR DEPARTMENT USE ONLY P `Applicai'ian Accepted by z 12 2" Dat Area Pit or Grout Inspection by ' Date Fina! Inspe n b Date i6-le 6'fo i Additional Comments: -e I i ❑ Stk 46_6-6781 _ El69- Lodi 33621 _❑ Manteca_823-7104 I ' —'Appiic'ant Return all copies to: Environmental Health Permit/Services_ 1601 E.EHazelton Ave., P.O. Box 2009, Stk., CA 95202FEE ire F � F INFO AMOUNT DUE AMOUNT REMITTED AS RECEIVED BY gD�ATfE PERMIT'NO. I + EH 13-241REV.)/s5) 1 Y 5,00 71 } 1 /�5? f �� j/`�//�S 0---Z- EH 1426 (/(/ Z _ 4 1