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APPLICATION FOR PERMIT JOAQUIN LOCAL HEALTH DISTRICT I, -X\i,. p\�1Pl� PAYMENT 4901 E. HAZELTON ON AVE., STOCKTON, CA RECEIVED Q0! �� + Telephone (209) 466-6781 - �0p.O�tJ+ ��r-f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED OCTg8$ 5� ��R �� (Complete in Triplicate) Il.. {� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install th^.Yk N ENT T !cation is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules& S Joaquin Local Health District. �^ Job Address FOO � 'CE� �'�"'� City CSD Lot Size PM � J/� g Owner's Name /y" D�L 4 `� �_ Address 9W T, (,/elvke �he Phone I�J4F Contractor J#—e)-,QW " /UJA&ddress OT-4E . APEN J=icense No. SfL� PhoneM�7-] P71 a _ TYPE OF WELL/PUMP: _ , NEW WELL._❑ WELL REPLACEMENT ❑ DESTRUCTION El Ont'1b ! PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ �Z— 1 It+� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE;h° garih�S I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPMS i . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation '�� pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing .44() Pyc. Specifications. 1W 41 i f-I Public r Other CI Delta Depth of Grout Seal Typ-1. of JGrout n I 1 Irrigation _Approx. Depth I I Eastern Surface Seal Installed byMPA& JPr�rlQar/_M�-: Repair Work pone ❑ Type of PumpH.P. State YVork Done Well Destruction 1 LJ Well Diameter 9 '-' f' Sealing Material (top 50') Lv o Mogi!' LJtd Depth -:ZO Filler Material {Below 50') IM _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is (� available within 200 feet.) J0 Installation will serve: Residence_-__ Commetcial_ Other (f Number of living units: Number of bedrooms Character of soil to a depth t?f 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments :IM PKG. TREATMENT PLT. ❑ Method of Disposal �� v Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size �M t FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number iM a SUMPS ❑ Distance to nearest: Well Foundation Property Line_,.-....�� DISPOSAL PONDS ❑ I hereby certify that i have prepared this application and that the work wilt 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 permitl�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, 1 sh l em loy persons subject to workman's compensa- tion laws of California." [>�to/Wldi�� The applican st call f II r uired inspections. Complete dra Ing on reverse side. GY Signed X itle: r Date: �rr11aL fJ. _ f FOR DEPARTMENT USE ONLY Application Accepted by Date f{% Area �IOlR17t�S _. . Pit or Grout Inspection by Date Akf!r Final Inspection by I Date �� 0 Additional Comments: SAN I(7Ari�l I (��g ILOAr �,rA T ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca I�3:]' 7Ni RONi14P � Applicant - Return all copies to: Environmental Health Permit/Services 1� n vl '�tk.. CA 95201 tl•p/'km. ,CA JIQX n a FEE AMOUNT DUE AMOUNT REMITTED CKRECEIVED BY INFO DATE PERMIT'NO. , a EH 13-24{FEV.I i>a 57 EH 14-26- i