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: i to APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 ReguFlations of the San Joaquin Local Health District. C v1 Job Address 4 . x.54 Ea-s t city .Ac.;cim p`,j Lot Size PM G(&.,doni JKas.t3 7��a:4 Easy vdofadb`ri cJ�e Owner's Name Address 4 Phone G*7 .30x 000 ContractorN or.th, VAL'LEY,; ,�;DRIq�ejp I!JG„ sG o-rn3fi gas "C_"01i�&an5e sato.'$8,34 Irhone " 6•»' 6'2 TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENTS.., -DESTRUCTION 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHU ❑ DISTANCE TO NEAREST: SEPTIC TANK " SEWER LINES DISPOSAL FLO.-r4 PROP.,LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11' 171Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Xir Dia. of Weil Casing 5 *f7 Domestic/Private q�0 Gravel Pack ❑ Tracy Type of Casing o� R :' . Specifications i '❑ Public ❑ Other F] Delta Depth of Grout Seal t Type of Grout Aloat' e"`y-- tj� I I Irrigation Tf _Approx. Depth l I Eastern Surface Seal Installed by rnvus, Repair Work Done ❑ Type of Pumps H.P. State Work Done_ �l Well Destruction ❑ Well Diameter ! Sealing Material (top 50') dI� Depth Filler Material (Below 50'1 �! TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION l I DESTRUCTION 1 1 (No septic system permitied if public sewer is 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: Water table depth ii' ' SEPTIC TANK ❑ Type/Mfg Capacity No. CompartmentsIil! PKG. TREATMENT PLT. ❑ Method of Disposal` Distance'to nearest: Well Foundation Property Line �I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: t Well Foundation Property Line SEEPAGE PITS ( I Depth -Size Number ~ �! SUMPS ❑ Distance to nearest: Well Foundation Property Line IM 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. 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, 1 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,1 shall employ persons subject to workiran's compensa- tion laws of California.," _ The applican ust call r all required i ctions. Complete drawing on verse side. ` Signed X Title: M& "'� �1 L �_ Date: FOR DEPARTMENT USE ONLY :µ A " e Application Accepted by P� Date Area Pit or Grout Inspection by � Date��®��e Final Inspection by I� Date 11 [I j �f# Y ✓ E'� r:� :'�T. j' Y'/ J� .,F -d.j,✓ .V 9"'Io"F' t'i Additional Comments: f r ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERlNIT NO. +.EH13-24(REV.1?n 5) /( ` ? ( EH N-25 II.