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i APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 iE 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. I� / i � Job Address ��l, �/�o City "f�10 Lot Size_ / Alie- J PM Owner's Name 'rte .//1"O19�C31°� Address /s .�cs?i�'i wi r `1 / i -- Phone i a .. �V !3 �G �I 7m License No. T?o Contracto _ Address _ �'� Phone _ I m TYPE OF WELL/PUMP; # � NEW WELL � WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ^` SYSTEM REPAIR ❑ ---� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK :J---'SEWER LINES 1'00'' _t DISPOSAL FLD./Bp PROP:LINE Lon_L+ .{------- -FOUNDATION k: ' )-�- AGRICULTURE WELL OTHER WELL — PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Ll Open Bottom C7 Manteca Dia-of Well Excavattio�rn Dia. of Well Casing ` XDomestic/Private Gravel Pack ❑ Tracy Type of Casing l' c- Specifications eh!sS- FI Public n Other ❑ Delta Depth of Grout Seat too Type of Grout°�f I I Irrigation ex. Depth I 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Wel?Diameter Sealing Materiak(top 50') Depth Filler Material (Below 501 TYPE_OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1,1 ,DESTRUCTION I 1 (No septic system permitted if public sewer is I. I available within 200 feet.) G Installation will serve: Residence_ Commercial_ Other f j Number of living units: - 1Number of bedrooms —"•� - = t.« Character of soil to a depth of 3 feet: _ Water table.depih (\� SEPTIC TANK ❑ Type/Mfg Capacity 5 No. Compartments I PKG, TREATMENT PLT. ❑ Method of Disposal � Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line t t SEEPAGE PITS I 1 (Depth Size Number ,I SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ II 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.Z 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 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 r1gist ca for all 're?7M pections. Compiete drawing on reverse side. W Signed X 4 CIx� � Title: C'Zt�1 4' /L" Date: ��7-,e ► NIENT USE ONLY -J ^ Application Accepted by Date -i Area [[�J Pit or r r ut spection by e Final.InSD ction by Dat Additional Comments: A �/� "�40 ' - e1 ❑ Stk 466-6781 ❑ Led 369-3621 F1 Manteca 823-7104 ❑ Trp4 835-6385 Applicant - Return all capias to: Environmental Wealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F y ' FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. �. INFO + EH 13.241REV.iix51 fU3'O EH 14-28fr/JI `� l/ - IN