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APPLICATION FOR PERMIT ✓47 SAN JOAQUIN LOCAL HEALTH DISTRICT ?"�' 1601 E. HAZELTON AVE., STOCKTON, CA � l Telephone (209) 466-6781 -�'GG� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) p ) 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. 50.9 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. / f� Job Address 7`3 0 t e a /fit) U�� !� � PM } ,c ( City C�� y Lot Size Owner's Name Address P.O. F Ja X �c / Phone Contractor — L�ess 5 Rr l Bo a License No.345015/ Phone TYPE OF WELL/PUMP: NEW WELL'�4 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR © OTHER El DISTANCE TO NEAREST: SEPTIC TANK OWE SEWER LINES L 1L�)1r�l,�,�F-_ DISPOSAL FLD.fl�,Ah�`, PROP. LINE �� ] �� FOUNDATION Q AGRICULTURE WELL U LCOTHER WELL I`�PITS/SUMPS / lJE INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �(Domestic/Private iX Gravel Pack ❑ Tracy Type of Casing rS!r�c— L. Specifications f"I Public n Other ❑ Delta Depth of Grout Seal Type of GroutC}LL %r� I I Irrigation --Approx. Depth I } Eastern Surface Seal Installed by _ Repair Work Done ok Type of Pump S lnl'n H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION l I DESTRUCTION I i INo septic system permitted if public sewer is s 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 �l LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line G SEEPAGE PITS f I Depth Size Number SUMPS Cl 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 O ' rules and regulations of the San Joaquin Local Health District. IINN i 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 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 Calitor� The applie t ust call for all r wired i ctions. Camp to drawing on reverse side. Signed X �Title: h �� (((t _ •, Data: FOR DEPARTMENT USE ONLY ��+ Application Accepted by �. Date 12 r�� 4C1 Area 0� N Pit or Grout Inspecti b Date 107-2-82 Final Inspection by Date Additional Comments: t ❑ 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 95201FEE 1 INFO AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT NO. +.EH 1324(RE EH 14-2e V.1/s el