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a ipA.11 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781. PERMIT EXPIRES TYEAR 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. _t, 1 Job Address 756 k�'vttlD C —_ City Lot Size PM Owner's Name I Address 2 30oq. Contractor Ek,-MLD r�t�IJt� Address�l 4$�LriS wQC�D�A.r�� License No. 13308 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT O DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM EP R ElOTHE � � OuL�2�tav w �S ( I DISTANCE TO NEAREST: SEPTIC TANK , SEWER LINES '" DISPOSAL FLD. PROP. LINE 1 I FOUNDATION f Z AGRICULTURE WELL OTHER WELL-1—S ' PITS/SUMPS &_L6- Q INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 2 r� ❑ Industria! El Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing ' e XGravel Pack' ❑ Tracy Type of Casing t- P�2 trc— Specifications 71 Public 1-1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation 9-;��W__Approx. Depth i I Eastern Surface Seal Installed by �� 7+r�+`5.i►7f� _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ 0 Well Destruction El Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i (No septic system permitted if public sewer is h available within 200 feet.? Installation will serve: Residence— Commercial_ Other 3` Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal St a 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 i I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ 1 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 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 applicant must callforall required inspections. Complete drawing yawn,reverse side. `,� I Signed X S �Ia�C`�� . ��7c t1t.c.>N Title: '"�"� ��V ' ��b�\ Date: KV'm,7 z-,, I!?,f38 FOR DEPARTMENT USE ONLY LI-5L y r` { Application Accepted by Date l5 Area W Pit or Grout Inspection by , Dat@ `� Final Inspection by Date I Additional Comments: / ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy( 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 . XJt �J INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. t EH 13.24(REV.i/H hl ) EH 14-2t1 c�L/ ti