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APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL.HEALTH DISTRICT l 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES"I"YEAR 'FROM DATEISSUED n : (Complete in,Triplicate) 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.54.9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address r i d * r� .f T City CYOV'- Lot Size 6 L 1,] b-.. . PM. 'F ( � g Owner's Name . i d __�LyT_r& a_ Addr&, 42 F' D 1 r �` Phone L I Contractor j Address License No. Phone I TYPE OF WELL/PUMP: NEW WELL ' WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION-❑., SYSTEM REPAIR ❑ 10TH -M DISTANCE TO NEAREST: SEPTIC TANK SJ' LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL tPITS/SUMPS 'INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T�cy Type of Casing Specifications (� ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout `t ❑ Irrigation ---Approx. Depth ❑ East..Q Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth -. .. ,�,Fill1r,Material(Below 50'1 I TYPE OF SEPTIC WORK:, EW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTR CTION ❑ (No septic system)permitted if 1c sewer is t available within 200 feet.) InstaAation will erve: Residen Commercial_ Other Number of living units: N ber of bedrooms Character of soil to a depth of 3 feet: W r tabletdepth t I SEPTIC TANK LJ Type/Mfg Capacity o. Compartments PKG. TREATMENT PLT. GD Method of Disposal Distance tone t: Well Foundation - Prope Line } LEACHING LINE' Ll Z& ngth of lines Total length/sieFILTER BED O nearest: Wel Foundation Propertt, Lin �J-'i4 � SEEPAGE PITS Depth Size Number SUMPS O"�Distance to'nearest:°^ Welles +- - Fon tion---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 District. I 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 work"man's compensation laws of California."Contractors hiring or sub-contracting signature l 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 ompensa-tion-laws of California:"--� _ . _-. _ � �--� -. �•�- - The applicant must call;for- II requirio s- Complete drawing on reverse side. ) Signed X • 'f r=' Title: ,�LK�+'�� Date 70 s. F,OR-DEPARTMENT USErONLY d . Application Accepted by Dater Area Pit or Grout Inspection /by/ J� le """s"� �—"`""Final Inspection by 1 Date ! �r Additional Comments: 10 a��m S T 7 P , 7-4[5 f.5' '�Vim. ❑ Stk 466-6781 El 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 95201FEE INFO T AMOUNT DUE; AMOUNT REMITTED RECEIVED BY DATE. PERMIT N0. + EH 1324(FEV:1/N 5) Eli 1429