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APPLICATION FOR PERMIT N JOAQUIN LOCAL HEALTH DISTRI, t/ 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466 8% g78'1y�0 PERMIT EXPIRES 1 YEAR FR0111I 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 her ' s is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules a I ons J uin Local Health District. Job Address�:m N�.'t �_►h� -t-�Juy-rd 1 t Az I I D co gas City Lot Size PM Owner's Name ` (1 h Address J�� C->'tk r &SK�.�7 2M��dene &S l7'3 Z C,,, • c? P C. 0( t V� Address �� .lZ-rY101/� License No. -2-146-," �Phonc� 7S3 ! ,� Contractor—c— TYPE OF WELL/PUMP: NEW WELL . WELL REPLACEMENT 1 I DESTRUCTION I I PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER a-^777,1/ e:vrf'rl r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 30"SD if DISPOSAL FLD. PROP. LINEA FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CI Industrial LI Open Bottom ❑ Manteca Dia. of Well Excavatio{ J _ Dia. of Well Casing 2` L1 Domestic/Private ❑ Gravel Pack❑ Tracy Type of Casing 1 `�C- Specifications f'I Public (1 Other fl Delta Depth of Grout Seal _ G�� _ Type of Grout I I Irrigation ___ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done IJ Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter 2— Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. n Method of Disposal Distance to nearest: Well Foundation_ Property Line LEACHING LINE 1.1 No. & Length of lines Total length/size FILTER BED I I Distance to nearest: Well __._ Foundation .. Property Line SEEPAGE PITS I I Depth Size Number _ SUMPS I I Distance to nearest: Well Foundation.____ Property Line DISPOSAL PONDS ( 1 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, 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applic must c for all requir d inspections. Complete drawing on reverse side. Signed lT�� Title: - (X�0 f�/ /S Date: .,4iQ,�LvK x"40 r�G�^4LSOCJI"Lt' R ARTE� USE ONLY Application Accepted by J c4'.; �// 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 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEEO AMOUNT DUE AMOUNT REMITTED CASH KAl RECEIVED By DATE PERMIT NO. . EH 13-24(REV. "51 EH It•2B