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APPLICATION FOR PERMIT J SAN JOAQUIN LOCAL HEALTH DISTRICTw 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED SEP 1 1959 (Complete in Triplicate) ��ee�� uu Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the�Wo� >twoh- �m "'i 't application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rubs' A�,'Rrl9&3`r�the San Joaquin Local Health District. w-r z r 0-aG 0(-4A'.4q Y Jab Address CE City 7PACV Lot Sim_� PM Owner's Name R,PF/IV��yr [-dN � J2(Qdress r6004w — Q Contractor qJ t cess S- e No. Phone TYPE OF WELL/PUMP: NEW WELD WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _ —DISTANCE TO NEAREST: SEPTIC TANK ./L SEWER LINES DISPOSAL FLD./4W_,4!,�77PROP. LINE FOUNDATION AGRICULTURE WELL — OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA�QNS y ❑ Industrial ❑ Open Bottom C Manteca Dia. of Well Excavation / _ ___-__ Dia. of Well Casing Domestic/Private Gravel Pack 'Tracy Type of CasingTAli /0 Specifications . F] Public 1-1 Other 1-1 Delta Depth of Grout Seal AQ�= Type of Grout I I Irrigation i,3VApprox. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 54'1 Depth Filler Material !Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION l I DESTRUCTION f I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ _ Number } - SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C 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 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." Contractor's hiring or sub-contracting signature certifies the following: "I certif 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." The applica t c r I requir spections. Complete drawing on re e e side. X de. �7/,,Ahv TitEe: ate: R DEPARTMENT USE O Y Application Accepted by Date Area' Pit or Grout Inspection by Date Final Inspection by Gate z / _ Additional Comments: /��/lS bra,- - r% '' ��y � �— s - S ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca 823-71 ❑ Tracy 835-6385 rta��/raducr e.cw2 .l q Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CSA. 95201 J NGed ruGl1 fu aC.zG(t amt e)Vor, IN O AMOUNT DUE AMOUNT REMITTED SASH K 0 RECEIVED BY /� DATE �PPERMITNO. FEE +,EH 13-21(REV. 55 h O * l 67-13 EH 14-28 V - �* Ill �( r a�'��/v�t�