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�F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTHDISTRICT y ` 1601 E. HAZEL T ON AVE., STOCKTON, CA 4 �'.a.' Cb Co Telephone (209) 466-6781 ; `" _ 4' PERMIT EXPIRES 1'YEAR FROM DATE ISSUED CL v y4 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wot _rein dscribe s application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulatio�t`,�' a San Joaquin Local Health District. Q r Job Address ° 1 04 12191City Lot Size PM 'r q3_ _ 3_ �7 Owner's Name •2 Address f _ � Phone R a r /J (� / I Contractor !� Address a C f"G License No. 3t�� --Phone_ I TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �[L� SEWER LINES DISPOSAL FLD (~., PROP. LINE FOUNDATION S^ ^—AGRICULTURE WELL OTHER WELL-1P�7Sl,SUMP_S, _ INTENDED'USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATICIPS fl T f ❑ Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f� /—Domestic/Private �Gravei Pack Tracy Type of Casing r I Specifications 6 d J (-I Public ❑ Other CI Delta Depth of Grout Seal OV '�' Type of Grout h eAA # I I Irrigation QM-.Approx, Depth 1 I Eastern Surface Seal Installed by 01&. 7i?7 _ I Repair Work Done ❑ Type of Pump H.P. State Work Done I Well Destruction ❑ Well Diameter Sealing Material stop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is b� available within 200 feet.) ,. ^ Installation will serve: Residence.. Commercial_ Other 1V/F4 Number of living units: Number of bedrooms 1. Character of soil to a depth of 3 feet: Water table depth f ^ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments J 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 j I SEEPAGE PITS l I Depth Size _ Number ��...SUMP_S - xa�f 1Distance_to nearest: -#We11 Foundation. PropertyLine 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 Di§trict. 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 Califor The applicant st, for al requi i pections. Complete drawing on r ,rsensid/e. 1 �J Signed Title: ` Date: G" 4pf FOR DEPARTMENT USE ONLY �� S Application Accepted by 11 ��`7 Date 4 Area 6 t . Pito Graut i coon b -� "" t h pe ymate _ Fnal Inspection by Date Additional Comments: kkjz:,. tae //U l0& ❑ Stk 466-6781 El Lodi 369-3621 Fq Manteca 823-7104 ❑ Tracy 1335-6395 Aopltct j Return all copies to EnvironmentAl Health Permit/Servir ,1601 E. Hazelton Ave -P.O. Box 2009 Stk ; CA 95201 .-tea°; // - ��,,:((n,-��.•�-�- `� a ` -�h y-�J^r��J�-_• �'e �7x'�7[,.'L��:"[.p. _ '=-f '�ir'.- 4-+ v'` I_U" /1••- INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. : ♦.EH 13.24 IREV.1 i H 5) Jis f1 ' EH 14-28 ✓ T__ -_. ��JJJ•••111 U I (i!!�� - .. !•-p-`�-- .. ,___ ,ray-«�� _�_ - -