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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E'-HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 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. Job Address 4&40 VEST ZAP. Cit 6Q9! w Lot Size ZZ-.4261 z PM kwner's Name'T ,_- t �jf�S L�G�21 C Lress��0+�X � 6b-�©G� Phone rL4Z.• 14 4%Contractor ! Address � &_'3T0CA<_T%)% License No: - Phone - A i T E OF WELL/PUMP: NEW WELL '❑" ' ' ` --WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i -_ DISTANCE TO NEAREST: SEPTIC_TANK.- � SEWER LINES DISPOSAL-FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca f1ia.-,of Well Excavation Dia. of Well Casing I ❑ Domestic/Private L1 Gravel Pack ❑ Tracy Type-of Casing Specifications t M Public F1 Other F1 Delta Depth of Grout Seal Type of Grout I Irrigation —_Approx. Depth.' I I Eastern Surface Seal Instalted by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Well Diameter 6? Sealing'Material (top 501 Depth __ Filler Material-(Below 50') LdJ TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ DDITION t ] ESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.! Installation will serve:-- Residence_ Crommercial_ Other j Number of living units: ` Number of bedrooms t . Character of soil to a depth of 3 feet: d Water table depth 17, SEPTIC TANK' ❑ Type/Mfg Y r Capacity. No. Compartments PKG. TREATMENT•PL-T--t~]� ri'`.,— -F �'4� Method of Disposal Q Distance to nearest: Well, \Fondation Property tine LEACHING LINE ❑ No. Bi•Liength of lines Total length/size FILTER BED Q Distance to nearest: We - Foundat n Property Line i i SEEPAGE PITS I 1 Depth ize _ ~ _ Number I SUMPS 0 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 District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of tate 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 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 of California." The applicant mut cal -fpr all required inspections. Complete drawwi�ingg on reverse si / q Signed X , Title�J� 1Ste Q 1SpIZ. Date: ENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 11 Manteca 623-7104 ❑ T,.ri3 y '835-&485 Applicant - Return all copies to: Environmental Health Permit/Services 16014'Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE T INFO• MOUNT RUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'Na. 4.EH13-24IREV.tins! 5��i lJ `- C QJ/\ J (� C(/ " !/✓ EH 14-28 r