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T 1 Gac�ty� { S CON) ) r APPLICATION FOR PERMIT S��p�N�SSAN JOAQUIN LOCAL HEALTH DISTRICT h 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 LPELT EXPIRES 1 YEAR FROM DATE ISSUED � 198.F? J � N�yS� (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the w&'I4 fj ' � ar�ication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules� MMERA San Joaquin Local Health District.it 64r- 17 Job Address •ACQGQ.. Ave. City RItCfn Lot Size PM Owner's Name �� Address-3/f W, , `/Q&'? Phones - 2109 �'ta 1,, 6-1 1 11 n Add000!4/ C.A .26-3-09 Pfi y15)3,,2,T- 1 Contractor Address 7t� License No. TYPE OF WELL/PUMP: NtW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ L / / PUMP INSTALLATIO ❑ SYSTEM REPIR ❑ OTHERX/f(liZ/T721- 1 bi►`CI� DISTANCE TO NEAREST: SEPTIC TANK Nfq SEWER LINES ASQ DISPOSAL FLO. N/4 PROP. LINE FOUNDATION ,vim AGRICULTURE WELL>_L61-0-� OTHER WELL-© ' PITS/SUMPS IVA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation -7/1 Dia. of Well Casing y /, ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PICC Specifications M Public ❑ Othgr F1Delta Depth of Grout Seal O O Type of Grout&Mln� ��°7 1 I Irrigation #0 12©J�ft pprox. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION LI 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 11 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, 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�n�ust�c-ahlyfor all ruired' s coons. Complete drawing on reverse side. Signed X •�/�T �- `, alacTitle: Ia �` Date: 91—IA? FOR RT E SE ONLY Application Accepted by Date — Area Pit orGrout nspection by Date /O 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 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO i� +.EH 18-24(REV.)i N5) ![�1 ``1`� $9 `- EH 14• / j� C j q „ 1 _` / AD