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y i -y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL' HEALTH DISTRICT ` 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED'' iComplet6 in Triplicate) ' I 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. iir, r ,"V:f`.'�1�'' 1 Job Address In/lYle ! ltt5��5 ��€ 'L 0�'1 City fl r LotYSiie PM Owner's Name"�efA r t L C1 J l kle✓f e S-'i r5k-Address SAM r Phone '3(08— � ��t S Contractor-i-kV12i Address ZA S License No. Phone 13qT TYPE OF WELL/PUMP:' NEW WELL 1W WELL REPLACEMENT ❑ DESTRUCTION ❑ !! PUMP INSTALLATION Ll �' -.:SYSTEM REPAIR ❑ OTHER 14 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 ti CONSTRUCTION SPECIFICATIONS ❑ Industrial }30 Open Bottom ❑ Manteca Dia.of Well Excavation �� Dia. of Well Casing y ❑_Dornbsltic/Private ❑ Gravel Pack ❑ Tracy Typeyvf Ca - sing ' V�� Specifications T ❑ Public N Other SAfi $4 ❑ Delta DepthiJof Grout Seal '-�� Type of Grout C nc,re�e i �s ❑ Irrigation 40LApprox. Depth ❑ Eastern Surface Seal Installed by K Repair Work Done ❑ Type of Pump H.P. t State Work Done fWell Destruction ❑ Well Diameter Sealing Material-Itop 501 ;r- r Depth Filler Material IBelow 50') ' ",".+ ' y TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is _, �.. available within 200 feet.) .� .Installation will serve: Residence Commercial_ Other '� ` Number of living uric s Number of bedrooms t Character of soil to a depth of 3 feet:I ! J Water table depth SEPTIC TANK ❑ Type/Mfg! Capacity No. C6 rtments PKG. TREATMENT-PL-T.-E-T *�- ` ^^" �^^s�' ^'"^""„""""'°"! Method of Disposal Distance to nearest: Well Foundation Property Line v 1' i LEACHING LINE v E No. & Length of,lines Total length/size Y FILTER BED ❑ Distance-to nearest: -Well Foundation Property Line ri SEEPAGE PITS "❑ Depth `. 1 Size f Number SUMPS ❑ `Distance to riearest."', jWell 1_F6un1dation 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, 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 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 st call for ire 1 ctions, Complete drawing on reverse side. i Signed Title: ' Date: 7✓/ S! A NT USE ON' Application Accepted Date Area # Pit or Grout In c' by Date _Final Inspection Date > S A itional Comme .�� d.o�1olrf.5 GWS r r^c37�5v.� ¢Y, " � '• KL5tk 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 95201FEE �- I INFO AMOUNT DUE .`{� AMOUNT REMITTED C SH RECEIVED BY DATE �' - PERMIT"N0. t EH 18-24(REV.7/a5) 7 ,.! �3�� K - ZL g3" R.5-,?q6 EH 1426 r {{ 11 VJJ6/�// Y ' y ��3j 8S •--Pc�._• -�P7o� cta -- Z taAd.a�-�a�� -�.� - -