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'i APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone-{209} 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 City S&ZIL L t Size Ed C 12 o PM I 7 C R Owner's Name 1 Address - ,. Phone V -r+...wi�..�.• •ww.wr.w.rt l r rwr „ „r�,: ��- ,-+iw,. � Contractor ddress `""`"""""' -License No.� d�^'"'phore TYPE OF WELL/PUMP: •+'— NEW WELL"E WELL_iREPLACEMENT ❑ DESTRUCTION ❑• PUMP,iNSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ' aSEWER LINES DISPOSAL FD. _,_ pROp. LINE FOUNDATION AGRICULTURE WELL OTHEfi WELL! "� PITS SUnAPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' r ❑ Industrials �. ❑�Open..Bottom„� p,-Manteca Dia..of.Well Excavation Dia of`Weil"Casing] ❑ Domestic/Private Gravel.Pack ❑ Tracy Type of Casing_ t PublicSpecifications 1-1 Public Othe ❑ Delta Depth of Grout Seal El Irrigation Type of Grout ! —_�1 prox. Depth ❑ Eastern Surface Seal'installed by Repair Work,Done ❑ Type of'Pump r, H.P. —°- State Work Done Well Destruction C1 Well Diameter Sealing Material (top 50') ■. C; Depth i M t Filler,Material IBelaw 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ii REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is f ' stallationwill serve: Residenc ✓ available^within 200 feet.) � k Commerc al�7 other Number ofaiving units: Number of bedrooms -� Character of soil to a depth of 3 feet: SEPit _ AI. % ; : Water table depth TIC TANK_ ❑.Type/Mfg 4 Capacity' No. Compartments f k PKG..T.REATMENT PLT. ❑ � �" �-�" �■ Method of Disposal t , 'Distance to nearest: WeyyII aN No Foundation Property Line Z• '� LEACHING'LlNE .� No. &Length of lines Total length/size FILTER,BED ❑ Distance to nearest: Well FoundationAo f � Property Line SEEPAGE PITSf p Size f! umber # SUMPS r❑ pDepth istance to nearest: WI MW Foundation ` DISPOSAL PONDS ❑ k Property Line I hereby certify that Lhave'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 folloWn l !o an � g: ""I certify that in the performance of the work for which this permit is issued, I shall not employ y y.person in such manner as to become subject to'lworkman'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 thisermit is issued, I shall em to tion laws of California." p p y persons subject to workman' compensa The applicarit call for all re ui inspections.pections. Complete drawing on reverse side. T I Signed X _ _C,� R f .. Title: Date: � - FO DEPF_ENT USE ONLY - Application Accepted by Date �'8b ,grga1 5 3 Pit or Grout l spection by Daie�� Final Inspection by 1. Date Additional Comments: ments: R Stk 466-6781 ; ❑ Lodi 369-3621 ❑ Manteca 823-7104 ElTracy 835-6385 + I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 -'FEE INFO AMOUNT DUE AMOUNT REMITTED CK —' RECEIVED BY � � CASH "", ,� _ DATE.) PERMIT'NO. + EH 13-24(REV.I M5) `�.J "' 'J '"'�" % ''� i `-F-• q� EH 14-2$ d .Z