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'\1\ 'APPLICATION FOR PERMIT -SAN`JOAQUIN LOCAL HEALTH DISTRICT E. HAZEL I ON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 7 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/ um and the Rules and Regulations of the San J Local Health District. p p Joaquin Job Address ��Sd.14716 /1L )�, A7? LS�j� City Lot Size PM Owner's Name Address/� Contractor d AddresY' Q d R�, c �� ' License No. .� Phone a?c.L?na�1� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT)) DESTRUCTION,0, PUMP INSTILLATION> SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK foo 75- SEWER LINES 11 � 74 DISPOSAL FLD,d7� PROP, LINE FOUNDATION c_3-4 AGRICULTURE WELL — OTHER WELL PITS/SUMPS �« INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excav i,o`n Dia. of Well Casin Domestic/Private Gravel Pack Ll Tracy Type of Casing_ Y Specifications C� 6'T); ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _1AA Type of Grout 7r� //♦ T I El Irrigation .4—OtApprox.j depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done ' Well,Destruction._T❑_ Well_Diamete� 6 Seaiin4l-Material (top Depth--t.T .-�-�-.-_,-�,.- Filler Ma#eTial"f9elow•50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑x(No septic stem p y permitted if public sewer is , avai le within 200 feet.) f J Installation will serve: Residen Commercial Other _ # Number of living units: Nu 'er of bedrooms t} I Character of soil to a depth of 3 feet: Water table depth G SEPTIC TANK ❑ Type/Mfg Eapacity No. Compartments PKG. TREATMENT PLT. ❑ tMethod of Disposal Distance t i nearest: Foundation _ Property Line LEACHING LINE ❑ No. & Length of lines - Total length/size FILTER BED ❑ Distance to neares Well ndation Property Line i SEEPAGE PITS ❑ Depth Size Number 6 SUMPS J ❑- -Dista a-to-nearest: -----Well` + " -•'Foundatron Property Line DI5P05AL_PONDS - ❑- �_.^._ a .�_ .. fit, k'e ,� �? p r ------------------ I hereby certify that I have preparect 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-L-ocel Health Disirict.�"-^} r Home owner•or,dicensed-agent's signature-certifies the following: "G certify that in the performance of the work for which this permit is issued„h shall not employ any person in such manner as to.4ecome subject to workman's•compensation-laws-of-California.”Contractor's hiring or'sub-contracting signature certifies th0ollowing:"I certify that in the'performance'of the work for which this permit is issued, I shall employ persons subject.to workman's com tioniaws-of-California:"- ---.u- pease- . The applicant st cal for all requd fns ctions. Complete drawing on reverse ide, Signed cl Si j r g ,tom Title: �a' ta' oy Date: 9-6 l0 FOR DEPARTMENT USE ONLY Appficati ccepted by 1J Date `-'' � �Area � 9 j Pit or,�ronspection by + Date_( Final Inspection by 7 Date f `S 1 ! CJ Additional Comments: ❑ Stk 466-6791 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638.5 Applicant- Return all copies to: Environrriental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY CASH DATE PERMIT"NO. + EH13.24 1REV. �a- EH 14.26 'l/•.•-US U� .