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�6JLI5 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 Co. �`P � � 3p ' ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to theA1. uin Local Health District for a permit to construct and/or install the work herein described. This application is made in comp) me with San JoaquiOrdinance No. 549for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health Wflcl Job Address T/�/ f J/ City/�-..57C.-V Lot Sue/zfeloX/sy pm'7"-5- Owner's NameQL� yAZZ" AAdd�dreesss..�� Pho Conlracl 5�4c6_.6.C/Addres /l/LCJIc-.X.1Li ic.,Tse No. Ph.. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CI Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing F1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public 17 Other 11 Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by 'V\` Repair Work Done L7 Type of Pump H.P. State Work Done_ C Well Destruction (1 Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIONA DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: R idance 4&, Commercial Q.1her Number of living units Number of bedroom / Character of soil to a depth of 3 feet: Water table depth / 0' D 1 SEPTIC TANK A. Q5721 Type/Mfg Capacity No. Compartments A PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. N Length of lines Total length/size FILTER BED C7 Distance to nearest: Well Foundation Property Line SEEPAGE PITS �� SUMPS Distance to nearest: Well 1 10V— Foundation -1.4G'7j— Property Line 5X40 DISPOSAL PONDS ❑ I hereby certify that 1 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: "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." The applicant must call for all required sp do . Comelete 4rawing on reverse side. Signed / ALA T'Ile: FOR DEPARTMENT USE ONLY ? c� �j�-> Application Accepted by ✓ Date 3' / /3 r'5 Area �� `A-.Grout Inspection by y� �( D to Final Inspection by Date"L',L_ r nal CoiiTr4lents: f2�I S ❑ Stk 466-6781 O Lodi 369-3621 O Manteca 623-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED 9Y DATE (' PERMIT -'NO. EH11241REV.1iw51 76,0(9 Chr 6!7 EH 14.N (1 V