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APPLICATION FOR PERMIT eP a SAN JOAQUIN LOCAL HEALTH DISTRICT r 3 J.. ►I 1601 E. HAZEL T ON AVE., STOCKTON, CA ®� —7 Z Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED o (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. ' s - r Job Address City /AJVQ,,1Lot Size PM Owner's Name — ✓-f�� U� G� ddress _ Phone µT L013, MEL ContraCtor a 19 _Address / C . icense No. g Phone TYPE OF WELL/PUMP: NEW WELL ; WELL REPLACEMENT 17) DESTRUCTION ❑ ; PUMP INSTALLATIONW SYSTEM,REPAIR..EYF s ,rOTHER IDt DISTANCE TO NEAREST: SEPTIC TANK _. .,_ SEWER LINES 1DISPOSALIFLD. r-_� PROP. LINE 25-0-' FOUNDATION AGRICULTURE WELL _,rr''OTF,iEf3 WELL_"-,,---- 1_ PITS/SUMPS � r INTENDED USETYPE OF WELL PROBLEM AREA CONSTRUCT ION.SPECIFICATIONS Ij ❑ Industrial LJ Open Bottom C1 Manteca Dia. af.•WeH�Excava[ion 2IL..— Dia. of Well Casing �( Domestic/Private �Gravel Pack ❑ Tracy Typ�C�g1 Specifications F] Public f-7i Other ❑ Delta Depth of Grout Seal Type.of Grout I I Irrigation ..Approx. Depth I I Eastern } ,rf ce Seal Installed by Repair Work Done ❑ Type of Pump ..H P, State Work Done_ I Well Destruction ❑ Well Diameter ��f; Sealing Material (top 501 Depth. 9'- Filler Materi4;(Beiow 501 ! ' TYPE OF SEPTIC WORK: NEW-INSTAL•CATION i l REPAIR/ADDITION' f I DESTRUCTION f I (No septic system permitted if public sewer I'S �1 f available within 200 feet.) J Installation will serve: . Residence Commercial_1 Other r Number of living units: mber of bedrooms a. t Character of soil to.a depth'of 3 feet: Water table depth r SEPTIC TANK Type/Mfg " Capacity— No..Compartments r LJf PKATNT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation ..Property-lane*; LEACHING LINE ❑ No. & Length of lines t. •" Total length/size f FILTER BED ❑ Distance to nearest: Well—,Foundation Property Line SEEPAGE PITS I I Depth Size _ Number l } SUMPS ❑ Distance to nearest: Well1 Foundation Property Lina i DISPOSAL PONDS ❑ r hereby certify that I have prepared this application and that the work'vJi1b be done in accordance with San Joaquin county ordinances, state laws, and rales and regulations of the San Joaquin Local Health Di$tricu- k Nome owner or licensed agent's signature certifies the following: "I ceetfy khat:in the performance of the work for which this permit is issued,I shall'not employ any person in such manner as to become subject to workman's campens -�aIaws_of Califarnia.'�Contractor s fiiiring of sub contracting signa`tire �. , certr res the following: "I certify that in the performance of the work for which thisn.. is issued,I shall employ persons subject to workman's compensa- tion laws of j The applicant m c , II equrred r ~ . Com)�jete drawing on rev se side NIA Signed X e Title: ` r h • r j +1..�.._�a�,;; .--.....�_�.,i;�: ,-_«-..�.._ .__..._.._�«.Y-.Date: r FOR DEPARTMENT USE LY J Application Accepted by x � Date Area Pit or Grout Inspection by 1 4 4 Date Final Inspe�n by Date 47,8'i$ Additional Comments: -7 1 I#S ❑ Stk -466-6781 GI-Lodi 369-3621----•---❑-Manteca 6237io4-M-� -o Tracy-8356385— -- _,_ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 FEE i AMOUNT RUE AMOUNT REIVI T.E_D CK RECEIVED BY DATE PERMIT NO. INFO -t' +�•w ; PCASH 1 +.EH 13-24(REV.r/K51 �� t-C._ •W y x�lhpl �� EH 14-26 ttt.�� 1 `U✓ Y •J ` �'j�