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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELi ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4?� j (Complete in Triplicate) ��. 071_ 0,10V —!53 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 Dista t. „r J Aadr�s Q(� aad t.t it,", Lot Size PM Owner's NameZ� ! Address a� rY,� i� �� f ane Contractorl. Ko X Address J ^ 4:�)+ 0 19.0 ( License No.L�Z3.7��Phone Za TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION-❑ PUMP INSTALLATION ( SYSTEM REPAIR Cl OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSDI?rH Industrial ❑ OOpen Bottom ❑ Manteca Dia. of Well Excavation r/ Dia. of Well Casing ❑ Domestic/Private M116ravel Pack ❑ Tracy Type of Casing Specifications ;� 1 t f-1 Public h Other (/['Delta Depth of Grout Seal O T pe of Grout_{�T4►-"7 X1_1 Q� (� I I Irrigation f,plapprox. De th I l E�_storn/� P Surface Seal Installed by J Repair Work Done D Type of Pump &. t�t�{�,p, 1� ? _ State Work Done — /ASArI/�IL Well Destruction ❑ Well Diameter (J 1111 Sealing Material (top 501 Depth Filler Material lBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION i l DESTRUCTION ! 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 1 PKG. TREATMENT PLT, ❑ Method of Disposal Distance 10 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 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line y DISPOSAL PONDS ❑ 1 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 Diltrict. Home owner or signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ an arson in such mann r as to beco a subi o workman's compensation laws of California." Contractor's hiring or sub-contracting signature Certifies a followin : "I certify aathape a the work for which thi mit is issued, I shall employ persons subject to workman's compensa- tion la sof Califor 1a. 1The ap licant m ca requ4, om drawing on e edell Signed X Title: Q Date: �J FOR DEPARTMENT USE ONLY Application Accepted by '9 Date Area �y Pit tau Inspection by Date 31 o Final Inspection IL aDate ACS Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED By `` DATE PERMIT'NO. j + EH 1 -241REV.tiH s1 \V �S�D �M 61 � ►p EH 14-28 r f