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� Y APPLICATIONrFOR,PERMIT SAN JOAQ.UINLOCALIHEA�LTH DISTRICT �q , 1601 E. .HAZELi ON AVE., STOCKTON, CA Telephone {209} 466-6781'�.a?.- 'f3rl. to -nk,I'i .� PERMIT EXPIRES 'I YEAFLOROM DATEJSSUED , 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..ir /� / .F �� i �f ' �`�� ` X53 f'J�: r?k4,rx#�� '('t�u T•�,+s 'i� �) �ttyl :JE 3 � Job Address e1U4rA2OL�.• 1►3•. f DO .A/"Of c, y DovO J�r2 City r Lot Size to Xnm � PM - . " Owrfer's Name Address Grryo� Contractor's Name License No. A „ *l 1$(�t'� � Phone TYPE OF WELL/PUMP: . NEW WELL. WELL REPLACEMENT O DESTRUCTION ❑ PUMP INSTALLATION ❑ ' SYSTEM REPAIR ElOTHER A Tis 1J R_ DISTANCE TO NEAREST: SEPTIC TANK �+O ri SEWER LINES 1F60 .DISPOSAL FLD. — PROP. LINE .Sn ' -FOUNDATION AGRICULTURE WELL; j.Q_�OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ';PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial .-.'X Open Bottom ❑ Manteca Dia. of Well Excavation .fl""—r?'' Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack E] Tracy Type of Casing £ Specifications 1g.Public TEST N/-u_, ❑ Other t :❑ Delta Depth of Grout Seal = _ Type of Grout El Irrigation L(tCLrApprox:-Depth :❑ Eastern Surface Seal Installed-by I Repair Work Done ❑ Type of Pump ) H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 DepthFiller Material'{Below 501 .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_ Commercial_ Other 1 Number of living units: Number of bedrooms y. # Character of soil to a depth of 3 feet:' ' -Water table depth SEPTIC TANK- ❑ Type/Mfg Capacity _ No. Compartments PKG. TREATMENT PLT. ❑ iF Method of Disposal Distance to nearest: 'Well Foundation ` " Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 4 FILTER BED .❑ Distance to nearest:,' '-Well! "j '^ Foundation Property Line' SEEPAGE PITS ❑ ,Depth Size F Number r - SUMPS ❑ Distance to nearest: Well ` Foundation' Property Line -� DISPOSAL PONDS ❑ ': t x t ? A 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 Sen Joaquin Local Health-District. -- -- 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. Contractors hiring or sub contractiga signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shell employ persons subject to workman s•e'ompensa- tion laws of California." . . The ap licant must call for a squired insyeptions. Complete drawing on reverse side. ' Signed V Title: o r, -1.2.L, P-1-S2 6f ' Date: _ Z' ; `' ` 1f . FOR DEPATM RT USE ONLY Application Accepted by Dots I Area , Pit or Grout Inspection by Date Final Inspection by Dates<- •�� Additional Comments: - — ❑ Stk 466-6781' ,r >rLodi--369-3821 4 -❑ Manteca 823- 04 - T ❑ Tracy,83r6385- w Applicant- Return all opses to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009,'Stk., CA 95201 f INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. r EH13-241fiEV.10!931 'V :��. a # _.f [ ,-•, - k ��f �CS �P'W`-1�� .t ,. EH 1425