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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES1 YEAR FROM DATE ISSUED (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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. J Job Address _. anee _ City ,,, IC*70W Lot Size,e 4V X3 0 r PM Owner's Name4 A_,2chwAddress ria zer-,V . Phone Contractor )41>q* Slj f ISS _Address. License No.�^T3Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C DESTRUCTION n PUMP INSTALLATION LJ SYSTEM REPAIR F1 _,•:, ,.OTHER-E7 �""� �`"'�`'✓ DISTANCE TO NEAREST: SEPTIC TANK -_� SEWER LINES DISPOSAL FLD.____... PROP. LINE 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _ Type of,Grout i ❑ Irrigation _Approx- Depth ❑ Eastern i Surface''Seal Installed by Repair Work Done ❑ Type of Pump H,P. _�. State.Work Done^ 1 Well Destruction 1 Well Diameter ._ f Sealing Material Itop 50') _ s " Depth . Filler Material(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ -'REPAIR/ADDITION a' DESTRUCTION 7`1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence-X_ Commercial Other < 44 Number of living units: —.!— Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mf C\ g 1 Capacity ___ No. Compartments PKG. TREATMENT PLT. I- f Meth, d of Disposal Distance to nearest: Well Foundation Property Line r , I ✓ I LEACHING LINE IN No. 8 Length of lines -W 40' Total length/size FILTER BED ❑ Distance to nearest: ,Wel /DD* Found tion *C Property Line--/47 SEEPAGE PITS 0 Depth Sizb �_�_._ —i _ Number !R SUMPS O Distance to nearest: Well /400 'Foundation 4©� Property-L-ine-i-cS 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 0 t Home owner or licensed agent's signature certifies the following:II.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 WW r1'k r,lihich this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The app' nt must call for all required inspect.ons. Cor late drawing on rev rse side. . rL \'i.ti�i:�"C\ ��vR3-•, V.v . Signed X Title: .- � � Date: ©7-.2/- 8� FOR DEPARTM NT USE ONLY L_�) Application Accepted by ._ 7 Date�_ - �__ Area Pit or Grout Inspection by �Daattey r,_ )3-M Final Inspection by Date J Additional Comments: _._��__..� /_`-��'�'r v+�""� ��L� __ '%=-� � ✓ ❑ 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 95201 I INFO AMOUNT DUE AMOUNT REMITTED CCASH RECEIVED BY DATE PERMIT'NO. EH 13-241REV.I%e h EH 14.2E