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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON TAVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' (Cornplete 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 Ryles and Regulations of the San Joaquin Local Health District. Jab Address ,1 7 a 'Sa. 1�iC�K�� L'4Nt City4 Lot Size a xPM I _O�0. So. CLrt�sCO/�6E L.4J Owner's Name ��LL (.Y�//llE-S Address Phone -14.6,40)( -7-69-702../ Contractor 7ZUi,V1A/Cf- 14912blG Address_ Z .l`7C A a l94C, License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM RE AP IR '❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSA-LN1 LD. PROP. LINE s + FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION'SPECIFICATIDNS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 5 Specifications ❑ Public yOther_.:.❑ Delta_..,.--Depth,.of.Grout,-Seal, —.Type.of.Grout-- ❑ Irrigation L—Approx. Depth ❑ Eastern Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump H.P. _ { State Work D ne Well Destruction ❑ Well Diameter Sealing Material (top 50'1IdRd WGIVV Below Depth Filler Material ( 50') �kA,,.�C_ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available,within 200 feet.) Installation will serve: Residence_ Commercial_ Other ! Number of living units: i Number of bedrooms f Character ofisoil to a depth of 3 feet: I _3.``°• "-` € Water table depth '':� t'5(.fdl SEPTIC TANK } ❑ Type/Mfg I ` Capacity No. Compartments �\, f PKG. TREATMENT PLT. ❑ �°�`' Method of Disposal Distance to nearest:- Well •R.n s 'Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest:{ Well FFoundation Property Line SEEPAGE PITS ❑ Depth t Size I Number SUMPS ❑ Distance to nearest:! Well Foundation Property Line l DISPOSAL PONDS ❑ I l 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. 11 Home owner or licensed ageht'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 ceify 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." t The appli t at cal required inspections. Complete drawing on reverse side. ' is �—•--ti `�J Signed �`--r + Title: �y r f�li"t-:2 moo. E n a✓�- -? Date: / 11 J� ��N N Z , I R G', 7'0,J(�rA1 F deo e470Afie, F P ENT USE ONLY Y Application Accepted by Date T Pit or Grout Inspec' r r Final Inspection by Date �aJr Additional Com s: ` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tra 56385 196re l Applicant- Return all copies'f6 Environmen`tal Fiealih PeFr it/Services 16iT1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i .. r FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE. PERMIT`NO. INFO C f + EH13-24(REV,v 8 5Y gy; - EH 14-26 g '�,