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E APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT �� 5, 1601 E. HAZELTON ON AVE., STOCKTON, CA ©0 Telephone (209).466-6781 k-e—F 01-P PERMIT EXPIRES 1 YEAR FROM "DATE ISSUED LC�Jq [_ (Complete'tri Triplicate} ( til 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. + 1 0 r, leg a Job Address _ S d S 4 L �/�c l/V�G�' ' City S'1rbG �` Lot Size PM Owner's Name U G 7-52 A�XCeS/ e 0 Address Phone 6 S- S-5 IC Contractor/f50 C C;S Address%dd 7SP �I S License No.37 73 Phone 37� y� TYPE OF WELL/PUMP: NEW WELI WELL REPLACEMENTof DESTRUCTION ❑ k PUMP INSTALLATION' _ SYSTEM REPAII ❑ OTHER ❑ } DISTANCE TO NEAREST: SEPTIC TANK �/scr�A —f SEWER LINES DISPOSAL FLD._/-I'D PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS C1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LJ Industrial ❑ Open Bottom ElManteca !Manteca Dia. of Well ExcavatioDia. of Well Casing Domestic/Private )Z Gravel Pack ❑ Tracy Type of Casing En S.4 Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Z -1" P Type of Grout �ti°� I ❑ Irrigation 'L-I-O-Approx. Depth ❑'Eastern Surface Seal Installed by <70A,:nSA c F6lt Repair Work Done ❑ Type of Pump -i�, H.P. 3 State Work Done Well Destruction ❑ Well Diameter r Sealing Material (top 50') Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet,) Installation will serve: Residence_ Com;t arcial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: "A, I Water table depth SEPTIC TANK ❑ Type/Mfg 5 Capacity No. Compartments PKG. TREATMENT PLT'❑ " Method of Disposal CA i Distance to nearest: Well Foundation Property Line �1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE-PITS ❑ 'Depth t Size -z-Number "."" SUMPS I].", 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. f 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 must call for all required inspections. Complete drawing on reverse side. p 4 Signed Title: Date: O J Z t-0 S FOR DEP MENT USE-ONLY Application Accepted by Date / GIGO Are, 6 t o rout I pection by Date Y�L Final Inspection ti _amu. - .... Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 j Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED .-. INFO CASH" RECEIVED BY DATE PERMIT"NO. _ZT TS X3T 10 OCJ _ + EH 131428 24(REV.1/$5) � ' ?g`g t S5- I31�'W EH �