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' APPLICATION FOR PERMIT t 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {2091 6-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Tri)licate) Zescr�jbed. Application is hereby made to the San Joaquin Local Health District for a permit t construct and/or install the work heretion is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No 1862 for well/pump and the Rules anoaquin Local Health District. Job Address JP.�1a�, ^��+ City l/ S Lot lie PM Owner's Name Address Phone 'S3 •-2 f f3�t3 C�n� .� Sufk3 Contractor I Address kdilii C 0 11 G64 No.A.SS5 6 Phonech TYPE OF WELL-/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑�'T DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM EPAI 0TH€R)iC VANP, Wim:, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELT_ PROBLEM AREA CONST TION SPECIFICATIONS- Il ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. o¢Well E avation /�j ' Dia. of Well Casing ❑ Domestic!Private Gravel Pack Ll Tracy Typof C sing Specifications 1-1 Public D Other ❑ Delta /inga pth of ro i Type of Grout/- d��. I I Irrigation �.Approx. Depth I 1 Easternurface nstalled by L'Pilt/fllst-� _ Repair Work Done ❑ Type of Pump H. State Work Done u Well Destruction ❑ Well Diameter She+. er p 50') rjp`ly Q¢yyu��a-h'^ Depth ,Filler Mate 1 elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATIO R ;AIR/AD, N i 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.I —, Installation will serve: Residence_ C mer Ott r Number of living units: Number Aims Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg k Ca acity No. Compartments PKG. TREATMENT PLT. ❑ I'MMethod of Disposal Distance eares4: ell Foundation Property Line LEACHING LINE ❑ No & e gth es Total length/size FILTER BED ❑ Dista n st: Weil _ Foundation Property Line SEEPAGE PITS ( I D th Size Number SUMPS ❑ istance to nearest: Well Founda ion Property Line DISPOSAL PONDS - - ❑ - T.- I hereby certify that I have repared this application and that the work will be doe in accordance with San Joaquin county ordinances, state laws, and rules and regulations oft San Joaquin Local Health Di§trict. Home owner or license gent'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 ch manner as to become subject to workman's compensa ion laws of California." Contractor's hiring or subcontracting 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 C - r a." The applican m call for a din tions. Complete drawing on r arse side. Signed X Title: t/�Ale- Date: v L • FOR DEPARTMENT USE ONLY �39 64 Applicatio Accepted by Oate Area Pit or Gr-ut Inspection by Date Final Inspection by Date Additi al Comments: ❑ St 466-6761 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT-NO. INFO +.EH13-24 IHEV. /n 51 (� q EH tl-28 �J 1•-• +4.?