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APPLICATION FOR PERMIT ., �j t� SAN JOAQUIN LOCAL HEALTH DISTRICT "" — C5 1rQ,,ri"' R ``t 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. ! '> . Telephone (209) 466-6781. iO DATE ISSUED cv 21 f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . (Complete in Triplicate) Application is:hereby made to`therSan 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. LB62 for well/pump and the Rules and Regulat ns of the San Joaquin Local,_-Health District. Jab Address 'µSubdivision Name .moi/ I� blex F. Owner's Name Address Phone f � 1 Contractor's Name License No. 091 Phone i -TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT [] DESTRUC7I0N ❑ PUMP INSTALLATION - SYSTEM REPAIR ❑# OTHER U 1 j DISTANCE TO NEAREST: SEPTIC TANK S SEWER LINES DISPOSAL FLO. PROP. LINE =2S r.� € V t 1, .F D p 70UNDATION —AGRICULTURE.WELL ,�-1 -OTHER.WELL w. :PITS/.SUMPS - 4 r~1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f a r I_1-Industrial s pen'Bot'tom'"F Mahteca'-Di 4 _F '�mestic/Private..r.._E]Gravel-Pack_[Q.Tracyy ,_.;Diaof We11�Casing �] Public Lj Other E] Delta Type of Casing ___. S,&e ❑ Irrigation Approx. ❑ Eastern Specifications J i Cathodic'Protection Depth� �, Depth of Grout Seal ❑Geophysical ? t Type of Grout �° to U Other ,� J Surface Seal Installed by poet [,F4-- r' , + Repair Work Done E] Type of Pump H.P. r! ��_ State Work Done 467rQ '' f W Well Destruction EJ- Well. Diameter Sealing Material (top 50') _ ` 3.r .depth.�� ,.8_Y '� Filler Material {Below 50'} � - TYPE OF SEPT.IC�WORK �NEW INSTALLAT--ION LI REPAIR/ADDITION LJ (No septic.tank or seepage pit permitted if public sewer is �.......�.,,, available within 200 feet.) � �- Installation will serve: Residence Commercial _ other Number of Jiving units: ',Nuber of bedr ms Y Lot size I Character of soil to a depth`of 3'-feet� � W meter table depth r" 4 SEPTIC TANKLj Type/Mfg Capacity No. Compartments f ' PKG. TREATMENT PLT. ❑ Type/Mfg -- �" 'LL Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line . DESTRUCTION ❑, LEACHING LINE ❑ No. & Length of lines Total length/size FILTER.�BED'-, ; b°=.❑-Distance .to.-nearest:,;YWelI Foundation Property Line { SEEPAGE PITS ❑ Depth size Number � SUMPS a 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 workinank compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I 'certify-that Jo the performance of the work for which this permit is issued, I shat - mploy persons subject to workman's compensation laws of Ca'lifornia." The applicant st call for re uired inspections. Complete dr -ngon rgverse e..- .Title: Date: 4 signed X ' FOR DEPARTMENT USE ONLY} Stk 466-6781 Appli ation Accepted by Area C l�- Additional Comments: 2� Lodi 369-3621 Pit or Grout Inspection by , Date ❑ anteca 8213_-7104 Final Inspection by ate L) Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk„ CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY ..DATE q PERMMIIT NO. 7INFO .�p �ia.: e� �TtLi 7`; EH 13-24 REV. 10/$2> 13 ,, -10/82 500 14-26