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Nup, APPLICATION FOR PERMIT wr' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 Rules and Regulations of the San Joaquin Local Health District. a`' Job Address 14 0 S ��+�_ �f �hd Rv�_ City C Lot Size M�``S�O�} PM C�� S r� t�} bW Owner's Name 73--V., Address M SaL Phone "CZ4013 Contractor I kress 0-140 FAS Qty hV License No."&1?0�Phone TYPE OF WELL/PUMP: W WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER % IDQ�R `% DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES IS-650 DISPOSAL FLDt. PROP. LINE s3sS© FOUNDATION AGRICULTURE WELL OTHER WELLS Q+i7 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT1 I�S /l r ElIndustrial ElOpen Bottom ElManteca Dia. of Well Excavati n Dia. of Well Casing 4L ❑ Domestic/Private tl(Gravel Pack ❑ Tracy Type of Casing Specifications (1 Public (1 Other 11 Delta Depth of Grout Seal SMQ�1 `Type of Grput l?R4 _ I I Irrigation Approx. Depth I I Eastern Surface Seal Installed byc��'l��nrr,c�, hast Z _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ tW�e ') ""ll Destruction ❑ Well Diameter _ Sealing Material (top 50 utaaut�kQ(`I a Depth'" Filler Material (Below 50') TYPE OF SE ORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I o septic system permitted if public sewer is available within 200 feet.) Installation will serve: idence Commercial_ Other Number of living units: umber of bedrooms Character of soil to a depth of 3 feet. Water table depth SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments _ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest- Wel Foundation Property Line LEACHING LINE ❑ No. ngth of lines Total length/size FILTER BED C1 rstance to nearest: Well Founda Property Line SEEPAGE PITS I I Depth ---Size r SUMPS LI Distance to nearest: Well .__ Foundation erty Line DISP L 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, 1 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 st call for all required i specti S. Complete drawing on reverse side. Signed X C" VrAY/1� Title: Date: � —7�7 FOR DEPARTMENT USE ONLY Application Accepted by _ Da�'d C..Pts Date Area Pit or Grout Inspection by Date. Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applliic�ant_- Return all copies ^to:,Environmental`Health Permit/Services 1601 E. Hazelton Aver., P.O. Box 2009, Stk., CA 95201 FEE I r INFO AMOUNT p�DUE AMOUNT EMITT CK (� RECEIVED BY DATE PERMIT NO. a EH 13-24(REV.i i n 5) ��) (� � 7 C�� / `� `C''�7 . .\ EH 14-28 4o.