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4, 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 fpr 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. Job Address O City(: SCALD zO Lot Size 15 I'PRe_S PM Owner's Name LZeG �219 n1Address7 SLvnJaApI Phone �2�," /22 + Yi Contractor's Namer)OBJ rI+L) PLA wJ2! 4 dA911 License No. 310oPhoneV J9"Q TYPE F WELL/PUMP: NEW WEL' :�, WELL REPLACEMENT DESTRUCTION ❑ t• 1 ��a�, PUMP INSTALLATION SYSTEM 4FPPAIIR ❑,y —�OTiIER-Q�- TANCEXfO NEAREST: SEPTIC TANK SEWER LINES �_ DISPOSAL FLD./[�Q'f- PROP. LINE t U# FOUNDATION AGRICULTURE WELLIUC)�tr OTHER WELLLQ0 PITS/SUMPS d0,4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEOFICATIONS © Industrial - ❑ Open Bottom ❑ Manteca Dia. of Well Excava-t-io�n Dia. of Well Casing # omestic/Private ' Gravel Pack ❑ Tracy Type of Casing S11-651, i Specifications ❑ Public ' ElOther 0 Delta Depth of Grout Seal Type of Grout '&0 0 ,(T f Irrigation ---4pprox. Depth ❑ Eastern Surface Seal Installed by . Repair Work Done ❑ Type of Pump H.P. State Work'Ddne""---- '\ Well Destruction 11 , Well Diameter Sealing Material (top 50') r I Depth Filler Material (Below 50') � 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: Number of bedrooms f ,, Character of soil to a depth of 3 feet:. Water table depth T SEPTIC TANK i ❑ Type/Mfg. Capacity--L No. Compartments' PKG. TREATMENT PLT. ❑ a Method of Disposal f 1 Distance to nearest:`� Well Foundation Property Line !+ LEACHING LINE ❑ No. Length-o#-lines_\-- Total length/size ! FILTER BED i. ❑ Distance to nearest:' Well Foundatiori Property Line SEEPAGE PITS ❑ Depth Size Number I SUMPS 1 ❑ Distance to nearest: Well Foundation Property Line j DISPOSAL PONDS ❑ " , ; 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."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, I-shall-employ persons subject to workman's compensa-- ` tion laws of California." applicant fiust Call`for alh�e�guited tri ctions`"Comple drawing'on-rev`efse-side` � /� Signed X. 7C t .,_ Title: Al V►^\ (, /�",, _ Date: i FOR DEPA Ef1IT USE ONLY Q i�-- Application Accepted by Date ' ^� J Area 1 Pit or Grout Inspection by Date Final Inspection by Date �4'�� v u{ w.c ! + lit 4-- �' O /ra✓ (�1't�-urd vwk) /1o1'�-eJ i Additional Comments: J I( I ❑ Stk 466-6781 EI Lodi 369-3621 Manteca 823-7104 El Tracy 835-6385 -[C f CCUf- Applicant- Return all copies to: Environmentdi HeaN Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED i. CASH RECEIVED 9Y DATE PERMIT"NO. J-� + EH 1324(REV.10193) ,Q [�� '�a,f� - S —\.o o ,_,� 10 EH 1428 �/\