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APPLICATION FOR PERMIT sa, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.—ION AVE., STOCKTON, CA Telephone (249) 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 22S-q 6' a �� Jy�• City F a 9'_\_Lot Size PM Owner's Name 1/e F, yr%'A Address 22 S1 o _/' 1�1�T2 /�l�c��, l V o'n Phone "d 9JS� Contractor �O I�1'I Address ,D Ox 6 C License No.`�:92& 23 Phone 9'33 �'� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ V f DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES 100 DISPOSAL FLD.1-00 PROP. LINE_ ©_ FOUNDATION AGRICULTURE WELL OTHER WELL/Qg:� PITSLSUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA- CONSTRUCTION SPECIFICATIONS 1 / ❑ Industrial ❑ Open Bottom ❑ Manteca *Dia. of Well Excavation Jf Dia. of Well Casing Domestic/Private Gravel Pack ~ Tracy.- 'Xype of Casing SpecificationsCh2 S5'{6Z) El Public EI Other C1 'Delta r' -Depth of Grout Seal Ij e � Type of Grout ❑ IrrigationAppro ,Depth r)❑ Eastern ' -Surface Seal Installed ree f t• Repair Work Done ❑ Type of Pump iS.L�b H.P. l State Work Done Well Destruction ❑ Well Diameter- +rte Sealing Material {top 501 _- �06� 14i Depth ! 7 Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is - � ,.available within 200 feet.) In ion will serve: Residence Commercial Other Number of livr -ts: Number of bedrooms Character of soil to a dep feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments dry, PKG. TREATMENT PLT. ❑ �� Method of Disposal` Distance to of W611 Foundation Property Line LEACHING LINE ❑ No. & Length of-lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property LineOD SEEPAGE PITS ❑ Depth Size Number SUMPS El 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 Sart_Joaquin Local Health District. ' y. 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`Califo_rnia." �. The appiicant,m'' t cal for all req 'red in pections. Complete drawing on'nFver�side. Signed.X Title: , a Date: _ TMENT USE ONLY Application Accepted by =lst�.M�(kM Date a' Area 1 �f �i1f Mr C er 3U6 -,tfVD frayc ru3 Pit oe Grout Inspection b 'o -Date,r' Final Inspection by Date Additional Comments:., ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-63855 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. + EH 13-24MEV.i/a553i4� EH 14-26. l V ��J�� 6