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� IE3 APPLICATION FORS PERMIT A SAN .10AQUlN LOCAL LHEALTH DISTRICT Avdr 1601 E. HAZELTON AVE., STOCKTON, CA ��fZA/qV j Telephone (2091 466-6781 11 PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED (Complete in triplicate) 'E,. ,I 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. Job Address +2-q (,Jts IAcJ<,-_P0yv( Str<et ;City. Lo u^ { Lot Size I I PM -f a a� Owner's Name M rti rcd fit' I d t� Address 42 1��e5 Iy �`^D 4 St. Contractor IYVM LXRIa1_C- h Address 28 E. Myrfter 56ek{D License No.64-51Z2(,E Phon2aq)'J'is$ "QL2l TYPE OF WELL/PUMP: NEW WELLX Z WELL REPLACEMENT ❑ DESTRUCTION ❑` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE ` FOUNDATION 1� r AGRICULTURE WELL , OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation rr � Dia. of Well Casing 2-11 0 Domestic/Private J$ Gravel Pack 13 Tracy Type of Casing FVC- Specifications i f`l Public f:1 Other n Delta Depth of Graut Seal r�0 y Type of Grout59° �DntFe ytr r I I Irrigalion 5 -Approx. Depth I 1 Eastern Surface!Seal Installed by Repair Work Done ❑ Type of Pump NA H.P, State Work Done _ t Well Destruction ❑ Well Diameter 2 I Sealing Material Itop 50'1 ' ° X 04o„tN6 EA41S Depth 55' Filler Material (Below 5O1 TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADOITION l I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) w 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 C f LEACHING LINE ❑ No. & Length of Eines Total lengthlsize FILTER BED 0 Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS LI . Distance to nearest: Well ___ Fouridation Property Line DISPOSAL PONDS C7 Is O I hereby certify that I have prepared this application and that the work will.5e done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I l 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 wcrkman'S compensation laws of California." Contractor's hiring of.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'work man's'compensa- tion laws of California." .. E .r^ f The appii n ust calif r a!I re fired inspections. Complete drawing on reverse side. Signed X C. -4 4131 Title:?{I'`cr c�C la c��° NS r (SIEA Date: IZ J Ie Gf L ]� FOR DEPARTMENTUSEONLY I 0� ,ST�2Z9. k Application Accepted by __ Date. Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: LIT-IF } Yy�] ❑ 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 FEE INFO DUE AMOUNT REMITTED CK It RECEIVED BY DATE OERMIT NO. iNfO CASH r � _ . EH 13-24 MEv.r i n 5) 412-24q� ��/y)EH 14-2flI � Y " ! ' 1 I• E� �'3