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Net. ." re his S o F 7- ve.r-y 16s c,^ APPLICATION FOR PERMIT ` a SAN JOAQUIN LOCAL HEALTH DISTRICT E. HAZELTON AVE., STOCKTON, CA W'� Telephone (209) 466-6781 01 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j (Complete in Triplicate) ere � rv� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install mrk herein descd .This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and thp Rules and Regulations of the San Joaquin Local Health Distr t. nlpt cy✓ Job Address o /�' /,`IJ/ 5400 T 1% A91 y �y�d y Lot Size PM Owner's Name Xs c V(�7Cy�i,Ci /C� 9�P�/C� �rSnQ�ne ,,,666 '(Address nn /�JJV '` —f� Contractorsg.� g. S eSrs License No. hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER)< DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public li']'15her ❑ Delta Depth of Grout Seal Type of Groutt ❑ Irrigation �4pprox. Depth ❑ Easternth�� Surface Seal Installed by �5 CC7 Repair Work Done ❑ Type of Pump Y H.P.— State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) v' Installation will Residence_ Commercial_ Other Number of living units: mbar of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foun Property Line — LEACHING LINE ❑ No. & Length of lines Total long FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 ap lic t m call for all re red inspecl'le s. Com a drawing o erre side. Sign L Title,40 D�`/�f. T �� 1n,� Date: �� 6 FOR DEPARTMENT USE ONLY / Application Ac P by 'vP Dat ��_6Area �Osa..} l+/✓.'yt• Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3W3821 ❑ Manteca 823-7106 ❑ Tracy 8356 Applicant- Return all copies to: En ronmental Health Permit/Servioss 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 fee ° X.' G� 61 - C,� v aD ` "FEE NFO MOUNT REM AMOUNT DUE AITTED RECEIVED BY DATE PEflM1T'NO. + EX 1a.24(REV.11.s) EN 14]6 ✓ CJ "I r0 i