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• � : �...'-�^+ -,rte .. �-�--- I I, APPLICATION,FOR.PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE,STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE-ISSUED t (Complete,in Triplicate) , 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. " IT F ;�y L07'n}U/� �f1}/J�+�vc�+ Job Address � r � '�`��', .. City. 0 Lot Size, M Owner's Name �y_1> -�- � C r� � Address Phone 't Contractor w 'Address License No. Phone; TYPE OF WELL/PUMP: ) i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ` �y" SYSTEM REPAIR Ll _ i OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK »---gEyy%ER LINESR''" � pIS�_S_ D. PROP. LINE i FOUNDATION AG AGRICULTURE WELL OTHER WELL PROP. UNE .� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ] ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private 1:1 Gravel Pack El Tracy Type of CasingS 1:1 Public Specifications ❑ Other L] Delta Depth of Grout Seal Type of Grout LJ Irrigation �4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done C] Type of Pump - H.P. State Work Done_ E Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 ` Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION K REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is f . i 4 � available within 200 feet.) Installation will serve:liResidence X Commercial— Other Number of living units: `' Number of bedrooms Character of soil to adepth of 3 feet: =A n_��` _ PillWater table depth SEPTIC TANK Type/Mfg 4..Z �f ' ' n.r Capacity � No. Compartments L PKG. TREATMENT PLT. ❑- i/7UC / p r r !`••� - Y'4, / ` Method of Disposal Distance to nearest: Well 0 4 property Line D ��-�•••--.."-- oundation LEACHING LINE 'No. & of lines �.�� -Length 0 t g d" %� ' n e5 T9tal' -- EDlength/size FILTER BED Distance to nearest: Well n ;4oundation Property Line T� p SEEPAGE PITS_"... �Q D"" ept"t'.a — „ - ' Sizes.`.-.. "„++ Number - I SUMPS_ _ r �s f �.y,. ❑T=�Distance'to'neares't: �' Well' - ,Foundation Property-Line DISPOSAL PONDS 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 follow employ any person in such manner as to become subject to workman's com ing: "I certify-that in the performance of the work,for which this permit is issued, I shall not pensation 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 to issued, I shall em tion laws of California." '� p y persons subject to workman's compensa- The applicant must call for all r u-ed ins ctions. Complete drawing on reverse side. 3 � ' F Signed Title: e '"! - Date: Aid �24 a i FOR DEPORTMENT USE ONLY Application Accepted by / a/ � Date Area Pit or Grout Inspection by ate ' ° D "t%Final Inspection by Date�� ` S +fir j. Additional Comments: l ( -r.-O�+ ❑ Stk "466-6781 ❑ Lodi 369-3621 ❑ Manteca .823-7104 '❑ racy 835-6385 tr Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 I t- 4 e � j i FEE AMOUNT DUE AMOUNT REMITTED : RECEIVED BY i INFO DATE PERMIT'NO. n: r EN 13-24(REV.vA 51`"'..."�..''_'^-'/-)- `- .� �-t•—..�. ,,,,, - .._: y,. EH 1428