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MU) 17A �Ir APPLICATION FOR PERMIT _ IG SAN JOAQUIN LOCAL HEALTH DISTRICT PA 1601 E. HAZEL T ON AVE., STOCKTON, CA R E G�Id D II Telephone {209) 466-6781 li PERMIT EXPIRES 1 YEAR FROM DATE ISSUED `? (Complete in Triplicate) �. N1'AL Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work here�ir 1NAQN n is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regul*g" Joaquin Local Health District: lif 40�K" Red �rePMJob Address Owner's Name sinte�(ti� C®rA• Address s$ZQ �/ C/"iLf Pr�lGe`� /�E�ls `�/rY�+3 "Z711 /1 !!_' Aq 7 5'.tr 1. 134-c-k-c- Contractor �'�U,tir�r U aft P fe[6t+ �Q aF3v t. �.la!• � CGr�[ se No. Y��3�� _Phon'e!�+� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ 11 PUMP INSTALLATION ❑ SYSTEM REPAIR 7 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �� �, r SEWER LINES 30 ft DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL /_e PITS/SUMPS LTA 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i '❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Io- + +'�� Dia. of Well Casing Z rYt� m tic/P iv a .k ❑ Gravel Pack ❑ roc Type of Casing specifications p4 Ofp r at Y 9 C"1 Public F Otv, V Delta Depth of Grout Seaty �� L�e�frMii 1 3_ype of Grou N� Gt' I I Irrigation Ll;i7Approx. Depth I 1 Eastern Surface Sedl Installed by @G C Im, _ Repair Work Done E Type of Pump r��l� H.P. State Work Donk G5 fNt 11.CtJ�II #14kCC si f7?LC Well Destruction O Well Diameter 1./mak Sealing Material (top 5011 "ate+ nem1r 3 Z �,I,t.. wuell�: �€ Depth ~ Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I l INo septic system permitted if public sewer is �! available within 200 feet-) i Installation will serve`: Residence______ Commercial T_ Other !Number of living units: Number of bedrooms i. Character of soil to a depth of feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Q Distance to nearest: Founda ' n Property Line LEACHING LINE I� ❑ No. & Length of lines Total length/size + FILTER BED I' ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS II I I Depth a _ Number SUMPS ii ❑ Distance to nearest: Well Foundation Property Line 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 N1 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:,,'1 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!" 1 The applicant must call for all e d inspections. Complete drawing on reverse side. Signed X Title: /" i� �/o Date: 3 113 1.054 �.sEN IU#c.r*NL � Aar�8y �i � FOR DEPAR N1ENT USE ONLY i Application Accepted by Date Area Pit or Grout Inspectio II by date{ = Final Inspection by Date 2-13 ,r f Additional Comments:i ❑ Stk 466-6781 11 ❑ Lodi 369-362f ❑ 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 I! INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED 8Y GATEFE- PERMIT N0. +.EH1 -24 1REY.,/n 51 EH 1 4-26 a ��ll EEtf� �'•� --• '-1