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e \ APPLICATION FOR PERMIT ' Y f. ry SAN JOAQUIN LOCAL� d HEALTH DISTRICT - EI 1601 E. HAZELTON AVE.'; STOCKTON, CA Telephone (209)'466-6751 PERMIT EXPIRES 11,YEAR FROM DATE -ISSUED l l (Complete inTriplicatel i;, 1 ii 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 arid Regulations of the San Joaquin Local Health District. �i ell sq II` iL ki Job Address 47-01 We,3 L�� GiT- 1 i City Lod t Lot Size `�-, PM Yi II Owner's Name M a✓ -tCi I U Til 0� WOl l Address 4CSO S'V. rr (A't Phone Contractor P�t1r[1m E le Sl°"� Address a$LS �- M + 5 License No.0 �512u8;Phone 209 1 yo-0&ZI TYPE OF WELL/PUMP: NEW WELL X I WELL REPLACEMENT ❑ DESTRUCTION''❑ PUMP INSTALLATION ❑ .:SYSTEM REPAIR ❑.,. �•. OTHER:,❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE V FOUNDATION +AGRICULTURE WELL "OTHER WELL � � :PITS/SUMPS INTENDED USE TYPE OF WELL ""PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom . . ❑ Manteca Dia. of Well Excavation Dia:"of Well Casing Z ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing PVG Specifications M Public Cl Other "'1 1 Delta '"""#'"-""',Depth of'Grout Seal,.— 40" Type of Grout I I Irrigation !j5__�Approx. Depth t 1 Eastern- I . :Surface Seal Installed by g t _ Repair Work Done ❑ Type of Pump NA - H.P. # ' T State Work Done Well Destruction ❑ Well Diameter Z" Sealing Material {top 50'1 1�pYtl b+rl Well Depth 55' Filler Material (Below 501 TYPIE OF SEPTIC WORK: NEW INSTALLATION [1 REPAIR/ADDITION Ll 'DESTRUCTION I I (No septic system permitted if public sewer is r r available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of livingunits: Number of bedrooms �" "� } Character of soil to a depth of 3 feet: Water table,depth e -41ki it � t3 2"91x1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartftients PKG. TREATMENT PLT.❑ ' +" + ""Method[ososa�i I_l'+ 1CAI a j Distance to nearest:- Well �t r:foliindatinn .Property Line 130014 t »" LEACHING LINE ❑ No. & Length of lines Total length/size . FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 as .`Rr e �-� SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well - Foundation # Property Line DISPOSAL 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 Di?;trict. Home owner or licensed agent's signature certifies the following: -1 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 Wing:"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 la of Calif rnia." f' The applica ust call If all re !red inspections. Complete drawing on reverse side. l.. Signed Title: 7 +h��IA^l' iST( SGrI�� Date: loGr04 3 P .. i IrT FOR DEPARTMENT USE ONLY Application Accepted by '_ 5i-__ Date Area 43'2+ Pit or Grout Inspection by Date .tkFinal lnspect on by 1'y.' Date Additional Comments: _Qr]_�J I S O f. _bo r �!- {-} ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca' 823-7�❑M;Tracy 835-6385. Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE ' TI — INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY r DATEa,Ili: :PERMIT'NO. X �I +.EH13-24(REV,t85) 2314y IM�1• - I• II .93. • �3 EH 14-28 LL// 1:114 ,. A .II 1