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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZEL T ON AVE:, "STOCKTON, CA _ /7'- ° Telephone (209) 466-6781 _ ^ .f yr ��1 } f PERMIT EXPIRES TYEAR FROM DATE ISSUED �Y — (Complete (Complete in Triplicate) a 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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1 cam}a�/3 �Ud� �VLjC1-1 1 Job Address �� City �T K N Lot Size j �e-e-E PM Owner's Name—7C L07A 011"64-'44 Address , m r Phone q31_3V 5 ewA4254mul4li)A4 Address License No. PhoneContractor1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION J0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l FOUNDATION AGRIC LTURE WELL OTHER WELL PITS/SUMPS pc3 INTENDED USE TYPE OF WELL PROBLEM ARXCONSTR ION SPECIFICAT[ONS ❑ Industrial ❑ Open Bottom ❑ MantecaWell Excavation Dia. of Well Casing❑ Domestic/Private ❑ Gravel Pack ❑ TracyCasing Specifications"I"1 Public ❑ Other ❑ Deltaf Grout Seal Type of GroutI I Irrigation __,.Approx. Depth fI EasternSeal Installed by _ Repair Work Done ❑ Type of Pump P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION { 1 DESTRUCTION f I (No septic system permitted if public sewer is / available within 200,feet.) Installation will serve: Residence v Commercial_ Other Number of living units: _ _ Number of bedroomsF n Character of soil to a depth of 3 feet: 4a..��,.. �.aa�..� 4t�CYnsw� Water table depth 3 � SEPTIC TANK Type/Mfg _ Capacity 12-00 No. Compartments PKG. TREATMENT PLT. ❑ r + Method of Dis osal 1 Distance to nearest: Well Ino_W Foundation ZS Property.Line LEACHING LINE CN"No. & Length of lines Total length/size so FILTER BED ❑ Distance to nearest: Well Foundation 1 Z S Property Line 2-S SEEPAGE PITS i*Depth Size �3 rt _ Number SUMPS Cl Distance to nearest: Well ISUfi Foundation "13Property Line j DISPOSAL PONDS ❑ 4 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 applicanm st all for II r r d ' s cons. Complete drawing on reverse side. Signed X � � ' Title: �� / ��"�� Date: �� " g F DEPARTMENT USE ONLY { Application Accepted by Date �~ `� Area s Pit or Grout Inspection by Date Final Inspection b Date d Additional Comments: L/ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- f5 { Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ava.1P,O. Box 2009, Stk., CA 96201 ' v r INFE AMOUNT DUE AMOUNT REMITTED CK 16 RECEIVED BY DATE PERMIT'_W0. -R +.EH 13.24(REV.i i H si 7r•p r0� EH 1♦-26 V 17,000 1 00 -67 '� 1 v '/Jt+