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APPLICATION FOR PERMIT 4/s 7 SAN JOAQUIN"LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone 12091 466-6781 �� 'sw~ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED s5 I .Ip D ( (Complete in Triplicate) FEB 2 0 ¢I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instalwlbJa wn fh� llT i a plication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and thi� �r#Regulalydr s or Joaquin Local Health District. I I 1/Z LL V?CE, I Job Addressi:C570 ►"U CityLot Size PM (/ Owner's Name Address �~ �� one �I� T'��0 � dl ��`` rr p r� Contractor "�� Address 6 �� Z3 ?3 TIS b-l �.1 - License�NO Phnrle ' TYPE OF WELL/PUMP: If NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ff PUMP INSTALLATION 2' SYSTEM REPAIR ❑ OTHER ❑ I" DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINlIE ~ FOUNDATION AGRICULTURE WELL i OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications .. �l .o. -'ems ._.-_._ �._ __ Public ❑ IOIther ❑ Delta Depth of Grout $eel � Type of-Grouf� I 1 Irrigation _'�I1_Approx.f Deh.' il'I Eastern Surface Seal Installed by Q-Repair Work Done IZ Typie of Pump/6`- '� H.P. � 0 t State Work Done ' I Well Destruction El Wel i I Diameter Sealing Material (top 50') ]p Depth Filler Material (Below 50) y TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION l I DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Resi'ence_ Commercial_ Other Number living units: �I Number of bedrooms - Character of soil to a depth of 3 feet. - Water table depth t SEPTIC TANK ❑ Type/Mfg Capacity lC P Y No. Compartments ' PKG. TREATMENT PLT. ❑ listance Method of Disposal to nearest: Well Foundation "Property Line 91' LEACHING LINE ❑ No. & Length of lines { Total length/size FILTER BED ❑ O istance to nearest: Well - Foundation —"-'—Property Line SEEPAGE PITS ! I Depth Size _ Number �M SUMPS L1 Distance to nearest: Weil Foundation Property Line DISPOSAL PONDS ❑ I hereby certify thai�l\have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations df the San Joaquin Local Health District. Home owner or licensed agent s signature certifies the following: "l certify that in the performance of the work for which this perm tl is issued, I shall not employ any person in suCFt manner as to become subject to workman's compensation laws of California." Contractors hiring or sub contracting signature certifies the following: "I certifykthat in the performance of the work for which this permit is issued, I shall employ �r tion laws of California." I` P p y persons subject to workman's compensa- tion I The applicant st ca for all required inspections. Complete drawing on reverse side. 1 ) Signed �! i11e: Date: i DEPARTMENT USE ONLY Application Accepted by / Date /` �` Area Pit or Grout inspection by I� Date Final Inspection byt Data_ Additional Comments: ❑ Stk 466-6781 ❑ Lodi�i 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant- Return all copies tot: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMtT'NO. II ♦.EH13-24(REV.1/145) 4= y M�' EH 14-29 o CTO i