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r s APPLICATION FOR PERMIT �€ # SAN JOAQUIN LOCAL HEALTH DISTRICT �.* 1601 E. HAZELTON ON AVE., STOCKTON, CA • s��nms�irw�a } Telephone (209) 466-6781 'NP- H1V11V3WNQ2lf/1 L- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) GM U 9 N Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein escrib d.`T�is application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rul� d�the San Joaquin Local Health District. �L N Z W A CI Job Address 1433 T, 1-a-IR L>swfs balivcity , S ' or �TAr kTOilf Lot Size DO 4 5 PM /0/ 5007H 10VAe_ke'ti bR,-E Owner's Name 05!q C D FtAe P_AT r&A1 Address Co NI C&Q40 . /t-L I Nt ALs. 4 Q_40 L Phone .CentractorAS E DFtu_tkNq. Address R D- SOX53 ?011 icense NoA492600 Phdh�e� 2 TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ a PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANK. SEWER LINES IDD' DISPOSAL FLD. PROP. LINE 30, FOUNDATION _L1_042 ' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial . ❑ Open Bottom ❑ Manteca . Ria. of Well Excavation !2 Dia. of Well Casing 0 Ilia Domestic ❑ Gravel Pack ❑ Trac T e of Casin , Y Yp 9 r Specifications 11-1 Public 1."44 r►4*hW Other s 171Delta Depth of Grout Seal 6' Jib 191 Type of Grout CCM C&r I I Irrigation _-Approxi Depth I I Eastern Surface Seal Installed by A5 E _bQ_f.LLtmC. Repair Work Done ❑ Type of Pump &PHIAL w_ H.P. State Work Done_ Well Destruction ❑ Well Diameter 2" Sealing Material (top SO') N 1,0r, R e H Depth 2G1 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION f I DESTRUCTION I ) INo septic system permitted if public sewer is I available within 200 feet.l Installation will serve: Residence- Commercial Other All 0/017meL*4 Number of living units: Number of bedrooms (� Character of soil to a depth of 3 feetF:' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal t, 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 1.1 Depth Size Number r SUMPS L1 Distance to nearest: Well Foundation Property Line i 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 Di1trict. 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." The applicant must call for all required inspections. Com plate drawing on reverse sides Signed Title: C. Date: ;D 9 a O ENT USE ONLY C� Application Accepted by Date r c ` Are Pit Gro nspection by ( v o, Date l f Final Inspection � 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, Silk., CA 95201 FFF INFO AMOUNT DUE AMOUNT REMITTED CK ir CASH RECEIVED BY DATE PERMIT'NO. • EH13-24IREv.rixsl EH 114-28a