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i - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 SSS ,�c�, 1601 E. HAZEL T ON AVE., STOCKTON, CA r ; Telephone (209) 456-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED �, �1 t (Complete in Triplicate) ,��/ Y 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 Dis;icL t. Roo so" Che'ro�k">�e -a/;e /,„� ' � Job Address City �`G Lot Size ,Z*Y 20�1 PM x Ow 's Na,((��fe •"'yo D(/ Co!"4 9 Address 900S� ` 'ems e 6/� Z� nerPhone f+W _ ni -9/0 /77a f57 shft>;Sw' ea s� 4 5/.5� �f Cy Ig-)46,,� ?_-17 7 Z_ Contractor(F'Y�/kcA_ �'� Address4ftlfChtlkL IV �rr4- CA License No.46'fSX+ Phdnfe- `07Of TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1MW-14 ,1eea PUMP INSTALLATION ❑ SYSTEM RTPAIR ❑ OTHER M_ �jQn DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - 9D DISPOSAL FLD- PROP. LINE FOUNDATION" 'YO f AGRICULTURE WELL OTHER WELL PITS/SUMPS _ h INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CQMf secs- a is edr``I°" If ahc.I c9r9W+ 11 (t it ❑ Industrial ❑ Open Bottom El Manteca pia- of Well Excavation pia. of Well Casing a2- 0 Domestic/Private ❑Gravel Pack ❑ Tracy r Type of Casing Sc_..+o 'QVC Specifications,9Al 76 ce-P-c + nPublic ❑-Other 171 Delta Depth of Grout Seal �1 �� Type of Grout,Z is+ o �+�°^+�__ I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by.d0-Va Qgmew+- Repair Work Done ❑ Type of Pump H.P. State W rk Done_ 1 8/, J Well Destruction Well Diameter Sealing Material (top 50'1 �o�- otekole OL a e AMA-,0i W/ 0 Depth '"�g/ Filler Material (Below 50') it n�►"HB W� a 7G-*r-or- TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: CIL Water table depth w SEPTIC TANK Cl Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ . Method of Disposal f Distance to nearest: Well Foundation Property Line l ., - LEACHING LINE 1-1 No. & Lengthpof lines Total length/size I FILTER BED ❑ Distance Ito nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ 'Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ k 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 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 lionl es'the following: "I certify that in the performance of the work for which this permit iso iss ted,Jt shall employ persons subject to workman's compensa- tion laws of Calif' i ." ._ d'raw�y� y � The applicant us coil for all.requi e - ,action. Completerd awing on reverse side. t Signed X ` i+"-��+ Title: �.�eGl fl-PO l aj�.TT Date: rre// �,S l«�'iggrn /( V FOR DEPARTMENT USE ONLY Application Accepted by Date ! / � t'`' Area Pit or Grout Inspection by . -r Date Final Inspection by 407 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all `copies ['to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk„""CA 95201 L y.. �OwS i 1.�. AdVc..nC � YOB jos i'9h )NFO FEE AMOUNT DUE pAjMOUNT REMITTED C 5H RECEIVED BY DATE PERMIT'NO. b, + EH 13-24{pEV,1/x5) '� PJ- �J EH 14-26 ,c.� s y L