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k APPLICATION FOR PERMIT z l SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZETON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 MAY 0 9 PERMIT EXPIRES 1 YEAR FROM DATE ISSUE �a�a AN JbAQUIN COUNTY (Complete in Triplicate) }/PUBLIC HEALTH SERVICES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or intall 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. 1J I Job Address o vv' PM I City T�`� Lot Size 2 X 3/ 7l I�7ur/S* art 's (_� Owner's Name P�'°��Address P, 0. ^'� Pholho ne 2� 5 i Contractor s-/c", Address a �11k X43/ 4,,W V. 9�63-521_icense No. 6-2 1617 Phone S1S.2<5t10 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 6aryDISPOSAL FLD. '^ PROP. LINE a D� FOUNDATION AGRICULTURE WELL " OTHER WELL 21:71 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LJIndustrial LIS Open Bottom El Manteca Dia. of Well Excavation `/ Dia. of Well Casing ❑ Domestic/Private 7 Gravel Pack Tracy Type of Casing PG Specifications I`I Public E Other Ll Delta Depth of Grout Seal Type of Grout ` I I irrigation __ Approx. Depth l I Eastern Surface Seal Installed by Sla.�✓xv Repair Work Done L7 Type of Pump H.P. State Work Done _ Well Destruction ❑ Weil Diameter Sealing Material (top 501 +_±! �.10,;� Depth Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITION l I DESTRUCTION I 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 ) Depth Size Number SUMPS Ll Distance to nearest: 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 following: "I certify that in the performance of the work for which this permit is issued, l 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 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 call for al requurrrred inspections. Complete drawing on reverse side. _•G('� Signed X �� _ Title: �+^r` �7` Date: D ENT USE ONLY Application Accepted by Date Are' Pit orro Inspection by _-L is Date Z• FO Final Inspection by Date& 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 85201 FEE AMOUNT DUE AMOUNT REMITTED CK O RECEIVED B DATE PERMIT'NO. INFO CASH ♦ EH 13-24(REV,If a 5) EH W28