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APPLICATION FOR PERMIT 1 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) �c 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 Ryles and Regulations of the San Joaquin Local Health District. Lo-'r o F- P-cw .;t:. Job Address 16 V �76 �r �4�P1 e tk City t'SL°CC�01�- Lot Size 404E, XU Mi PM - Owner's Name0.r+e5 �2W�/�� Address 6 20C S WTgN p '.. -�� "Phone 3 d 3 Contractor S_ e l l- Address 6 ?c _5� 1"u y�� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ; DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS,RL'FLD. PROP. LINE j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE STYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' (� v ❑ Industrial ❑ Open Bottom!'. ❑ Manteca Dia. of.Well Eiicavation _ - "'' Dia. of Well Casing I] Domestic/Private El Gravel Pack []'Tracy Type of Casing " ' ¢ N-,Specifications ❑ Public ❑ Other `. ❑ Delta Depth of Grout Seal ' �' Type of Grout ❑ irrigation --Approx. Depth 5'❑ Eastern Surface Seal Installed by '- Repair Work Done ❑ Type of Pump H.P. State Work Done 1 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ ESTRUCTION,❑"(No septic.system permitted if public sewer is: available within 200 feet.) Installation will serve: Residence 1--/1 Commercial_ Other Number of living units: Number of bedroomsf Z Character of soil to a depth of 3 feet: j Water table depth SEPTIC TANK � /M Typefg +� Capacity 0 No. Compartments Z� l PKG.TREATMENT PLT. ❑ i ! -- Method of Disposal Distance to nearest: - Well _ Foundation`�p f J=Property-Line-�// LEACHING LINE ;VcL No. & Length of'lines. �ry� To al length/size ` o FILTER BED ❑ Distance to nearest:'�`,..;;.'INell Fou dation�� Property Line r SEEPAGE PETS s" ❑ Depth Size __X,IFX 0 Number SUMPS'--- Distance to nearest: Well Foundation;'l�,_.-�4/ Property Line G tl DISPOSAL PONDS ❑ Y� I hereby certify that I have prepared this application and that the work will be done in accordance-with San:Joaquin county-ordinances,�stateaaws; 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 perhYrmarice`df the work for which this permit is issued,JI shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 app lic st cal r all regaed inspections. Complete drawing on reverse side. Signed Title: a6w Date: FOR DEP TMENT USE ONLY Application Accepted by Date Area i Pit or Grpection by Date Final Inspection by Dat Additio o�ments: f&& if Vviiw 0, sec'>)JrkAl eff -V .Gs,PL Z,—_Jd 5-V ❑ Stk 466-6781 . ❑ Lodi 369 1 Vmanteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental 1464 Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE �P}ERMIT`NO. + EH13-24IREV-1/651 S� °� 14-l' � 5- 14 - EH 1426