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APPLICATION FOR PERMIT %POF SAN JOAQUIN LOCAL HEALTH DISTRICT Lvd 1601 E. HAZELTON AVE., STOCKTON, CA #,�lZA�fj?i Telephone (209) 466-6781 "f 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 andlor 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. Job Address +Z9 U45+ Lock_ r Sfirt�t City �� E Lot Size I 1 -•ra PM Owner's Name arl�fc .,k 10 Address -42-9 On+ U<kcA4 S •, S*,-(>_ Phone p -� Lodi f CA Contractor S_1?i!Td�U_w1 EXPIQ(r-�OP) Address ZSZS t. MyrrKC1 5V0400A art License No.�51-512Z(°'S phone yoq)_,`Ib -Q(2�4 TYPE OF WELL/PUMP: NEW WELL Z WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1, ❑ Industrial ❑ Open Bottom L3 Manteca Dia. of Well Excavation Dia. of Well Casing 2 0 Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing PVC Specifications L f`i Public ❑ Other ❑ Delta Depth of Grout Seal 40 Type of Grou157-bu Unit� r� I i Irrigation 55r Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump h1A H.P. State Work Done _ Well Destruction ❑ Well Diameter zn Sealing Material (top 50') X f4*AtfbIin LA41S Depth 55 r Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line lav LEACHING LINE ❑ No. & Length of lines _ Total length/size FILTER BED Li Distance to nearest: Wel€�_ _- Foundation Property Line SE=EPAGE PITS 11 Depth Size Number _ SUMPS d_I Distance to nearest: Well Foundation _ Property Line DISPOSAL PONDS ❑ Q I hereby certify that I have prepared this application and that the work vJill be done in accordance with San Joaquin county ordinances, state laws, and l ' rules and regulations of the San Joaquin Local Health Di'strrct. Home owner or licensed agent's signature certifies tho 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, I shall employ persons subject to workman's compensa- tion laws of California." The appli n ust call f rr all re ced inspections. Complete drawing on reverse side. Signed y Signed X_ ��#4931_ Title:'B'�11610sG C-t�S f SCfl(,09_ Date: 1L !E -1 Z_ FOR DEPARTMENT USE ONLY Application Accepted by _ ___..___.__ _ __ Date ! ' ' Area —- w(o(Itis�c-�-,Ih CVN !1.2z �� Pit or Grout Inspection byj� ,L� 1 gyp) Date y� r p�`pFinnaaii�Innsspection by Additional Comments: V s a 5� 1` f ,r v f>— COL, e -+ ' 'C int ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 5601 E. Hazaiton Ave., P.Q. Box 2009, Stk., CA 95201 tFEE AMOUNT DUE AMOUNT REMITTED �}CA�S(]"1 �RRECEEII/V��ED By DATE PERMIT NO. . EH 13-24 IREV.i,H5l ��rr - �� r L2�rlq If 1 �� r�• EH 14-26 111 __ __�� I�