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04!89 1 1 : 03 F' . 2 4 C011VEQ „ APPLICATION FOR PERMIT ldAN SAN JOAQUIN LOCAL HEALTH DISTRI �9�� 1601 E. HAZEL T ON AVE., STOCKTON, Telephone (2091 466.6781. PERMIT EXPIRES 1 YEAR FROM DATE 1 SUED (Complete in Triplicate) IJAN 3 C� Application is hereby made to the San Joaquin Local Health District for a permit io construct ang7o'tlir&j ht}work h, a9descri ed. This application is made in compliance with Sar,Joaquin county Ordinance No. 549 for sewage or No. 1862 for well IpuIr ;� s and Regulations of the San Joaquin Local Health District. iL�� Ty /�V �1erUE_i4T Ni__5L-ul G N City Unuuco►cPoR►f7��Lot Size ' 300�4e+PEs PM .fab Address � " �� Y r ?M +Jf v� Address 2 ' 'CIA Phone Owner's Name flu CA Contractor f �� 'ctrrt/� Address � �� LIfEwrY � License No,.�'�3� �3G __-Phonet916 771-a TYPE OF WELL/PUMP: NEW WELL 171 WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION f'? SYSTEM REPAIR ❑ OTHER r< 50iL $cAt'N4s DISTANCE TO NEAREST; SEPTIC TANK _ „_ SEWER LINES ► __ DISPOSAL FLO.— — PROP. LINE cc FOUNDATION AGRICULTURE WELL ,__ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [] industrial C1 Open Bottom C? Manteca Elia, of Well Excavation Ula, of Well Casing Fj Domestic/Private 111 Gravel Pack I-i Tracy Type of Casing-- Specifications I'i Public I.i Other 11 Pelta Depth of Grout Seal __ Type of Grout —._. I i Irrigation —.Approx. Depth E I Eastent Surface Seal Installed by - Repair Work Done L3 Type of Pump H.P. _ State Work Done_ Well Destruction ❑ Well Diameter _,_ Sealing Material atop 501 - r Depth __ Filler (Material (Below 50•! _ -- TYPE OF SEPTIC WORK; NEW INSTALLATION I I RI'IIMWADUIT1ON I ) DESTRUCTION I 1 (No septic system permitted i1 public sewn, is available within 200 feet.) lnstalfaiion wit _ Aesidenea ^-.-_ Commercial Other Number of living unitsi umber of bedrooms—.. Character of soil to a depth of 3 feet: _ .., Water table depth SEPTIC TANK L1 Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well tion Property Line LEACHING LINE Ll No. 8 Length of lines _ Tot th/size FILTER BED ❑ Distance to nearest: Well , ._ Foundation_ Prope SEEPAGE PITS l l Depth .Size _ Number - SUMPS la Distance to nearest: Well Foundation__ Property Line DISPOSAL PONDS Fl I hereby certify that I have prepared this application and that ilia work will be done ill accordance with San Joaquin county ordinances, state laws, and rules and ragOations of the San Joaquin Local Health Di$trict. Home owner or licensed agem's signature certifies the following: "I certify that in the performance of the work for which this permll is issued, I shalt not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following "I certify that in the pet•ormance of the work far which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all r quired inspections. Complete drawing on reverse side. Signe -- Title: �E111T1S�. v+ ke G 6 FOR PEPARTl1�ffT USI: Q � 4. Application Accepted by ------..._��2 , Date Z' O AtaaPit or Grout Inspection by DateFinal Inspection bue..u::ii .-. .— Additional Comments: ❑ Stk 466-6781 0 Lodi 359-3621 ❑ Manteca M3-7104 ❑ Tracy 835-$385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2(109, Stk„ CA 95201 FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT•NO. INFO f ..EH 13-24Oev.r/nSf EN t4-2e r