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I - APPLICATION FOR PERMIT rk SAN JOAQUIN LOCAL HEALTH DISTRICT ;i, 1601 E. WAZEL i ON AVE., STOCKTON, CA } Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JUN II f 1967 (Complete in Triplicate) XNVIROMENTAL HEALTH Application is hereby made to the San Joaquin local Health District for a permit to construct and/or install the work rejR VJS��tion is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and ft o the San Joaquin Local Health District. E Job Address XM 7 / �� ^'_�` City Lot Size ` PM Owner's Name !r ' Addressagi; �+�� Phone r' Contractor w�+ �r"I Address License No.6 9 E241 Phone TYPE OF WELL/PUMP: 4. NEW WELL ❑ WELL REPLACE NT ❑ DESTRUCTION ❑ PUMP INSTALLATION, SYSTEM REPAIR Jf OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL. FLD. PROP. LINE �} i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS C INTENDED USE TYPE OF WELL I PROBLEM AREA CONSTRUCTION SPECIFICATIONS j ` ❑ Industrial ❑ Open Bottom ' ❑ Manteca Dia- of Well Excavation Dia. of Well Casing t �} 4 f�Domemic/Private ..L] Gravel Pack L1 Tracy Type of Casing SpecificationsiP v i F`1 Public 17 Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation �� -Approx. Depth l I astern Surface Seal Installed by �M d S ��/� Repair Work Done ❑ Type of Pump �4b "-H`P. f / State Work Done_ Well Destruction ❑ Weil Diameter „ p Sealing Material {top 50') DeuY pth Filler Material (Below 501 �� l -TYPE OF SEPTIC WORK: NfW INSTALLATION l l' REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is l available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms G Character of soil to a dept0of 3 feet _ Water table depth SEPTIC TANK ❑ Type/Mfg T Capacity y No. Compartments �M PKG. TREATMENT PLT. ❑ f Method of Disposal �M !i Distance to nearest: Well Foundation Property Line ! t LEACHING LINE ❑ No. & Length of lines Total length/size Ik FILTER BED ❑ Distance to nearest: Well Foundation Property Line I, SEEPAGE PITS I I Depth Size _ Number iM SUMPS L1 Distance to nearest: Well Foundation Property Line �- DISPOSAL PONDS' 0-0 I .. _ � 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 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." II - i!'The applicant must f a Irequ'ed in ctions."Complete drawing on reverse`side:° Signed X Title: Date: II II; FOR DEPARTiMENTSE ONLY Application Accepted by Date ' Area:' - Pit or Grout Inspection by ! Date Final Inspection by (l/. Additional Comments: il �Ip ❑ 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.D. Box 2009, Stk., CA 95201 II �, FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH t EH 13-24{REV.I/x5) / _04-77,1 EH 14.26 U X/! �I;�� {{ k