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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZE T ON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED 0 C T 0 f 19.9Q (Complete in Triplicate) PU SAN.I0AQ;q,kJ C`)UNTY Lr,; d� Application is hereby made to the San Joaquin local Health District for a permit to construct and/or install 1 � -� e r �f .1`IiiiQ1cata re1n made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the u s }Ye&Ia66Ai,i6f0 9 Local Health District. O{7 r cat N Job Address 1448 N. E1 gorgiC1n Street City.S_Lc]cktnn Lot Size 290 X 79SI PM 5kCfZk**.TTb (35815 6 1 on Owner's Name1S'��n�i Prt��nart.i PS Address 1 7�5_ Chc1IQ _ Phone — i . Z�Z �2Er,t�r�>tiss .CTD �" _ ;.. ' Address 3 �} .., i_se No.�LQ_16 —Phone 0 Contractor.. Hoaat , L1�omvc> `�' - - TYPE OF WELL/PUMP: NEW WELL N P1 P3 � WELL REPLACEMENT ❑ DESTRUCTION Cl �'r 0Es✓ r PUMP INSTALLATION ❑ r8SYSTEM REPAIR ❑ OTHER 7q _A+O-,F_ V.)GLLG DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 50' DISPOSAL FLD. PROP. LINE 35' FOUNDATION AGRICULTURE WELL OTHER WELL 25' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 10" _ Dia. of Well Casing 2" ❑ Domestic I Private []t Gravel Pack ❑.Tracy Type of Casing SCh 40 F480 PVC Specifications 5% BenbmAbe I'1 Public 171 Other O? Delta Depth of Grout Seal 15' Type of Grout Nit 0mmt.- I I Irrigation 40`_Approx. Depth 1 I Eastern Surface Seal Installed by WaSb�M (19� D�iM) Repair Work Done 0 Type of Pump H.P. State Work Done — Well Destruction ❑ Well Diameter _ Sealing Material (top SO') Neat Cmmt tenth 5% Eimbotrite ,--� Depth Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) I 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 I, FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE: PITS I I Depth Size _ _ Number SUMPS L-I Distance to nearest: Well Foundation Property Line , DISPOSAL PONDS ❑ 1 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 aqd regulations of the San Joaquin Local Health Di§trict. 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 i 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." The applicant must" all for all re spectiohs. Complete drawing on reverse side..- q �j Signed X _ Title: yL _.__� J� Date: 1 0�tG +h-. FOR DEPARTMENT USE ONLY / Application Accepted by _ Dat r d Area Pit or Grout Inspection by Date Lv-..J--.----) Final Inspection by Date r € Additional Commerits: ❑ Stk 466.6781 ❑ Lodi 369-3621 nteca -7104 dh Tracy 5-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 EEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO 1 11 EFI13-t11REV.,i�ti, ¢`q EH 14-2e