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- "' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ; 1601 E. HAZELT0 AVE., STOCKTON, CA E Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED Y.i.. (Complete in Triplicate)' '- Application riplicate)'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 Ryles and Regulations of the San Joaquin Local Health District. , Job Address 8 Country Club 'Blvd. city' Stkn.v,` 'Lot siie 82x194 PiUI Owner's Name Adin W. .ROda `=Address 1954 -Canal Dr. v Stkn :�._._.. Phone 4633"..5859 Contractor OWIler .z L Address- _ License--No:. Phone TYPE OF WELL/PUMP: -NNEW WELL pWELL REPLACEMENT-❑ DESTRUCTION [I.\ ' PUMP IN_STALLATION ❑ SYSTEREPA AREST: SEPTIC TANK b SEWWER LINEM _ R„p_ . OTHER-❑ d DISTANCE TO NES DISPOSAL FLD. PROP. LINE FOUNDATION..— AGRICULTURE WELL, ( ,.OTHER WELL _ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom F1 Manteca Dia, of Well Excavation r Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public Q Other_ , _Delta Depth of'Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by j Repair Work Done- ❑ Type of Pump H . State Work Done Well Destruction L Well Diameter Sealing-Material (top 50') Depth t Filler Material iBelow 501^ f f x TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ bESTRUCT NX o septic system permitted if public sewer is , r F available within 200 feet.) Installation will serve: Residence— Commercial._., Other t Number of living units: Numtie of bedrooms i Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK I ❑ Type/Mfg Capacity-"" No. Compartments PKG. TREATMENT PLT. ❑ r * 'Method of Disposal s Distance to nearest: Well Foundation 4, Property Line LEACHING LINE ;j. ❑ No. & Length of lines r t 4'F, Total length/size fry FILTER BED ❑ Distance to nearest —WellF.oundationl Property Line SEEPAGE PITS ❑ Depth 'F Size f Number r I SUMPS ❑ADistance to-nearest: WellFoundation Property Line } I �k v oper DISPOSAL PONDS ❑ I hereby certify that 1 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 si nature-certifies the following: 9 9 g: "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 -i 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.- i, , ; r The applicant m II for all required i " t ns. Complete drawing on reverse side. SignedTitle; O wner Date: 6117/85 - FOR DEPARTMENT USE ONLY r y Application ed b - { PP Accepted P . Y Date ` 1Area I4 , +. -- Pit or Grout Inspection by jDate Final Inspection Date A ditional Comments: Stk 466-6781 t3 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 835-6385 I licant- Raturn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 � FEE AMOUNT DUE �' AMOUNT REMITTED E INFO CASH RECEIVED BY DATE PERMIT NO. _ + EH13-24(REV,i La 5) EH 14-26 - a1-. •4 "_ --