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I APP'LfCATIGN'FO'R PERMIT� { SAN UOAQUIN LOCAL HEALTH DISTRICT ll� 1601'IE. :4ZELTON AVE.,. STOCKTON, CA . Tetephorie (209) 466-6781 i pERMIT'EXPIRES 1 YEAR FROM DATE ISSUED i k (Complete in Triplicate) i I � t 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 an Joaquin County OrdinanceNo. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the�San Joaquin Local Health District.with 00��" l,J w Joh Address Cs City Lot Size— I— PM ib Owner's Name �; ddress / Phone ��" I v tE j j �� Phone k Contractor ddress! License No. TYPE OF WELLIPUMP: NE WELL X! WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATI0"1 SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST:.SEPTIC TANK �D SEWER LINES DISPOSAL FL-D. PROP. LINE t I /L � FOUNDATION - — AGRICULTURE WELL OTHER WELL PITSISUMPSJJ'f t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION'SPECIFICATIOI�zS f� t F Industrial fl Open Bottom ❑ fjAarteca �t+Z�pDia. of Well Excavation � ( Dia. of Well Casing-- ❑ Domestic/Private Gravel Pack ❑ Tracy �` I Typo of Casing, Specifications �'J F 1 Public Cl Osher F 1 11elta f tDepth of Grout Seal Type of Grout -A r s I I Irrigation pp ax. Depth I i Eastern Surface Seal Insatlled by � -- �:G��1T�/�� l� - Repair Work Done 0 Type of Pump H.P. I State Work Done T� r t Well Destruction El Well Diameter Sealing Material Itop50'1 l ! j '" 4 Depth Filler Material`(Blow.!50'1 f 4 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 1 DESTf3UCTION I 1 JNo septic system permitted if public sewer is available within 200 feet.] t d installation will serve: Residence_ Commercial .,Other T r Number of living units: Number of bedrooms C Character of soil to a depth of 3 feet: 1S j '.. T_ f- r Water table depth SEPTIC TANK ❑ Type/Mfg X11 ', 41 Capacrty t moo. Compartments ,5 Method of Disposal ^ PKG. TREATMENT PLT. ❑ t Distance to nearest: lF Well Foundation Property Line + R t l � LEACHING LINE ❑ No. & Length of lines I '.• - -- o1ai-Ie79tf1/size FILTER SED © 'Distance to nearest: Well 'Foundationf_ Property. Line til 1 SEEPAGE PITS I Depth Size SUMPS L7 Distance to nearest: Well jFo ndatl on �J Propert Line DISPOSAL PONDS ❑ i += �'� I hereby certify that l have prepared this application and that the work wilt,be:tdrie,i}L.accrdnce-with-San Joaqurn county ordinari7 estate fa,ws,`and rules and regulations of the San Joaquin Local Health Di§trict. t t Home owner or licensed agent's signature certifies the following: "I ceEtifty that t In the performance of�therwork ficK�hlpermit isssu ,jl s �lnot employ any person in such manner as to become subject to workmans`compensation laws of California." Contractcs's hiring or"ut2-Aractmg signature certifies the following: "I certify that in the performance of the work forwtiich this,permit,is.issued, I shall employ peraons subject-tt�vriorkrnan 5 compensa- tion laws of California." The applicant s squire c Complete drawing?bR reve�_side r Signed X Title: k ��=-e` ! FOR DEPARTMENT USE O, Y Application Accepted by r !i bate -D- i� Area `p. -- i ! Pit or Grout Inspection by fate S`f Final nspection Date Additional Comments: -r ` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 w Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. r ') +.EH 13-24 IREV.r i H 5) � � �Z � ^� Z Y � EH 14-26