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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT € k`� 1601 E. HAZELTON AVE., STOCKTON, CA ( � C Telephone (209) 466-6781 ~ F 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. II^ �^ Job Address �� 4� /' ,,-y^ %'p 7 0-;V MCity f Hh Lot Size el a An,m PM Owner's Name l�t .� ru la v I Address q%1 7 "45 C" `tl1 sY IAA'w recc, Ph one Contractor's Name o _40'_-' License No. f q� �C13 ��7J Phone TYPE OF WELL/PUMP: NEW W LL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER;❑, DISTANCE TO NEAREST: SEPTIC TANK 1-7e)* _ SEWER LINES /A/0FL . DISPOSAL D. Gd "PROP. LINE L�_: FOUNDATION AGRICULTURE WELL OTHER WELL A 44ZPITS/SUMPS &ewe D f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_afE Dia. of Well Casing � Domestic/Private Gravel Pack ❑ Tracy Type e of Casing n+ � 9 Ca�C � Specifications CJ`d S� � ❑ Public ❑ Other ❑ Delta Depth of Grout Seal T pe of Grout A/e-a Ce_ ❑ Irrigation '1 Approx. Depth ❑ Eastern Surface Seal Installed by COJ l- 1�e-, f RepaV Work.D'one' ❑- Type of Pump4S'O) 1 H.P. _ State Work Done / V"„ �. Well Destruction ❑ Well Diameter Sealing Material (top 50') - Depth Filler Material (Below 501 E TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:r s Water table depth SEPTIC TANK C1 Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ ` Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 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." Contractors hiring or sub-contracting signature € certifies the folldwing:"'1 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 applicant must call for all required inspection C mpl to drawing.on, verse side. Signed Title: d Date: FO DEPARTMENT USE ONLY Application Accepted by �"' 15-r !� Date Id'� � Area Q� Ph or Grout Inspection by Date !f` +—)fFinal Inspection by Date Additional Commants: f ❑ Stk 466-6781 ❑ Lodi 369-3621 NlfManteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental 4eaTth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE +� AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO." '+ EH 13-24 1REY.101831 _ - r ,`zj,� -• C'� 4sS'L3ZE; f EH 1428 111