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APPLICATION FOR'PERMIT t. 1' SAN JOAQUIN LOCAL HEALTH DISTRICT ? 1601 E. HAZEL T ON AVE., STOCKTON, CA t. Telephone (209) 466-67131 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) =; Applicclion is n.neb, •o t.r .an Jo.lquin Local Health District for a permit to construct and/or install the work heroin described.This application is made in compli,na,v,.9,S, r. ..in County Ordinance No.539 for sewage or No. IR62 for well/pump and the Rules and Regulations of the San Joaquin - Local Health Disiricr Job Address �l ) �--Vy 1 (,+,O J4 City ,' 1 IkAjTle 0� Lot Size �O tT v A.P—f PM C(L -72 -) 2. �Ir��aL�wv r X23 8SS1 Owner's Name —__ Address _ hone _ Contractor=t"� 'Ce A,.dress- ISO NU l� J N&License No.2(/M/ S PhoneAn <,Sav y TYPE OF WELL/PUMP: NEW WELL. ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ l PUMP INSTALLATION O SYSTEM REPAIR O OTHER O + DISTANCE.TO NEAREST':_ SE°TIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE 0:WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial :7 Open Bottom ❑ 1,'antece Dia.of Well Excavat on Dia.of Well Casing r; Domestic/Private 1.1 Gravel Park ❑T=,icy Type of CasingSpecifications i'1 Public L:Other F1 De:'a Depth of Grout Seal Type of Grout _ I I Irrigation ___Approx. Oeplh I I Eas:9rn Surfoce Seal Installed by Repair Work Done ❑ Type of Pump _ _ H.P. State Work Done_ Well Destruction 17 Wel'Diameter Sealing Material Itop 501 _ Depth Filler Material(Below 50') — 3. TYPE OF SEPTIC WORK: NFvV INSTALLATICN I I REPT IR/ADDITION I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation wiil serve: Residence__ Commercial.— Other- Number of living units:—_ Number of bedroom; p Character of soil to a depth of 3 fent: Water table depth SEPTIC TANK O Type/Mig __ Capacity Na. Compartments M,G.TREATMENT PLT.Osposal Method of Di r-- ; Distan:e co nearest: We I_—_—_ Foundation_ Property Line LEACHING LINE L No. &I ength of lines Total length/size FILTER P_SD ❑ Distancr to nearest: Well- _ Foundation Property Line v f SEEPAGE PITS I I Depth --- Size_—_ Number SUMPS Ll Distance io nearest: Well_ Foundation Property Line DISPdSAL PONDS ❑ I hereby certify that I have prepanyi this application anc that tht work will be cone in accordance w,th San Joaquin cu .,y ordinances,state laws,and rules and regulations nf the San'Joaqu.n Local Health 03trict. Home'ownet or licensed ager.,,',signature certifies the following: certify that in the performance of the work for which this permit is limed,I shag not i employ any person In such r, r as to become subject to workman's con,pensation laws of California."Contractors hiring or sub-contracting signature ' certirtaill the following: car:ity that in the petiormance of the wort:for which this permit is issued.I shall employ persons subject to workman's compensa- tion laws of California." t a The>yp6licanL,py,ILcall for cared ins (tions. Complete drawing on rove•se side. / L Signed X_ �---. , z Title: v N d` Date: ._ t OR DEPARTMENT USE ONLY T Application Accepted by —C V Date7 arae Pit or Grout Inspection by _ Date Final Inspection by nate + Additional Comments: D Stk. 466.6781-- 0 Lodi 369.3621- -Manteca 823.7104 ❑Tracy 835.6385 Applicant- Return all copies to: Environme. jlth Permit;Services 1601 E. Hazelton Ave., P.O. Box 2009,Stk.,CA 95201 FEE AMOUNT DUE AMOUNT REMITTED Ck of CASH RECEIVED BY GATE PERMIT'NO. _ j. . EH 13-24 IREV.tear Q co EH 14.26 -< ._,_'______.,_....�,�.y, ��15y�wt�y, py sf,"r,-t:.a:.4t•r:utv,a�.m..+esus;S::ta'2'.:>�c(.taY+'�'1t+iA' Yi`"�f ''^RiY. ^�•`Y,< g' `f - k tr�tl f• t t+.