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ry APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �i 1601 E. HAZELTON AVE., STOCKTON, CA pp Telephone (209) 466-6781lC , tIT1�.�' PERMIT EXPIRES 1'YEAR FROM DATE ISSUED iCamMete in Triplicate) 1,44f 1/� b 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. Job Address %�t>� �•/��`•-' +?� 1I. __..— City Lot Size_ It/ /7C� PM I Owner's Name �1 �ddress r� f![� allMPI) Phone �:�4 71 Contractor Address 7 [�C.JD f ! License No. Phone yy -TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71DESTRUCTION ❑ I PUMP INSTALLATION L) SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout - I I Irrigation _..Approx. Depth I ] Eastern � Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. Eh State Work Done _ W Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I ) DESTRUCTION I I (No septic system permitted if public sewer is �,// E available within 200 feet.) Installation will serve: Residence_ Commercial_ 'Other'f i l � Number of living units: —/— Number of bedrooms �f f Character of soil to a depth of 3 feet: 159I - Water table depth /00 SEPTIC TANK I�Type/Mfg �' Capacity_1 � No. Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation / ® Property Line io+-y I). t LEACHING LINE No. & Length of lines Total length/size a FILTER BED ❑ Distance to nearest: Well Foundation . Property Line IM SEEPAGE PITS Depth Size_/&16W3 Number SUMPS Cl Distance to nearest: Well _Foundation Property Line . DISPOSAL PONDS Li -' I hereby certify that I have prepared this application and that the wotk will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. It { 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-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." 1 The applicant m t call for all required inspections. Complete drawing on reverse side. ISI 9-31-87 Signed( Title: L ��- Date: IIZWLy1V N 5'T b1°M4, Pf1+J +'FOR DEIPARTMENT USE ONLY 1 - Application Accepted by r Date �� Z `� � Area ` ie. ) CPit r Grout Inspection y� Date Z7 -Final Inspection by I�Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-74104 ❑ Tracy 835-6385 { Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Boz 2009, Silk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED �i CK RECEIVED SY DATE PERMIT-NO. MrH t.EHt3-24)REV.t ir55Y ` �"'1/�1 pCY �r�1 i. EH 14-28 - 1 tJ`' V ice' �/"+r ✓[