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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. i 1f 1 a p�"L��E'SD/U A �E City,._.5.7w':! _ Lot Size 3�Z A PM Job Address ,L Owner's Name`.A2f-iiff27- -14Y7 gAFZZ4Z Address '�� ...XFQE RU-,&'.tiA AYL5 .___ Phone 471? 23 iS' Contractor l-t' D W00:D r Address�Q_�gJ: j.I LL./A� 1} F Y -VC-License No.42L! Y24 Phone "377/ \� TYPE OF WELL/PUMP: NEW WELL ❑ i WELL REPLACEMENT ❑ DESTRUCTION U PUMP INSTALLATION ❑ I SYSTEM REPAIR C OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. - PROP. LINE FOUNDATION _... . .._ AGRICULTURE WELL OTHER WELL.____— PITS/SUMPS _ INTENDED USE TYPE OF WELL e.. P-ROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑.Open.Bottom U Manteca ! Dia. of Well Excavation Dia. of Well Casiirtg Is 1 C Domestic i Private ❑!Gravel Pack U Tracy i Type of Casing—... Specifications * Public n Other. 1+ I7�Delta Depth of Grout Seal Type of Grout-- * Irrigation x.:Depth CJ' tern Surface Seal Installed by _ ....__ r� Repair Work Done U Type of Pump— C . ._ H.P. __. State Work;Dol* Well Destruction C Well Diameter` y 1 Sealing Material Itop 501 _ t % 4.',. 4 Depth T° --.1 ' Filler Material IBeI 50'i TYPE OF SEPTIC WORK: NEW INSTALLATIONIF7 REPAIR/ADDITION DESTRUCTION F. (No septic system permitted if public sewer is 1 T r t available within 200 feet.) Installation will iGry -Residence� Commerciaal�'� �Other Number of living units: —I— Number of bedrooms Character of soil to a depth of 3 feet: I Cu-A y _ _. —Water table depth SEPTIC TANK M""Type/Mfg I C C --Pl(-L ;No. Compartments ?- ;EKG. TREATMENT PLT. +'-1 l r Method of sal Distance to nearest: Well t L0 Foundation Property Lime LEACHING LINE L' No. & Length of lines Y I STD--1& Total length/size ?.__-___._� FILTER BED I Distan'W"nearest: Well _ Foundation Property Lirie^1 SEEPAGE PITS L] Depth 1 r _U34$7-7 AJG Number ... SUMPS Cl Distance io nearest: Well Foundation Property Line I � t f DISPOSAL PONDS ❑ i '• 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. ! j 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 subcontracting signature certifies the following: "I certify that.in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of California." i The applicant must call for all required inspectio s- Complete drawing on reverse,side. Signed r. ._._ Title: C_17+ - ! Date: -- ! t FOR DEPARTMENT USE ONLY Application Accepted by � _...— Date Pit or Grout Inspection by Date Final Inspecti by 1,7 64%I Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 fl Manteca 823-7104 ❑ Tracy 835-6385 7 Applicant- Return all copies to: Environmental Health Permit/Servicea 1601 E. Hazelton Ave., P.O• Box 2009, Stk., CA 95201 i FEE AMOUNT DUE i AMOUNT REMITTED C1C RECEIVED BY DATE PERMIT'NO. INFO CASH / + EH 13-241REV.r ae) -7O . U U EH 14 28