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t I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT fx 1601,E. HAZELT ON AVE., STOCKTON, CA D } Telephone (209) 466_6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUE FEB -i-aE57— 4 (Complete in Triplicate] Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install RR"TftENINIftn J�plica4on is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ft 1ffltythe_San Joaquin Local Health District. /.7a= �+�� ]fir �Grnplr dT' I/Q1 l7� (/t Job Address HT � i City r'/aa7rr , .c –Lot Size j PM ' 5-at!,� say Paayul� Owner's Name q9% K_Q,-r,71. AddressPhone 3/6 �' �� ^— Contractor �P �? for Address � �t lw License No. ?fir_ l 95�� Phone –7D TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT PL. DESTRUCTION ❑ v1 ; PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, -_PROP_._LINE_- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ 1.. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS & ❑ Industrial ❑ Open Bottom ,Manteca Dia. of Well Excavat" Dia. of Well Casing ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing— f5-J1�gxe Specifications . ❑ Public ❑ OYher ❑ Delta Depth of Grout Seal Q- Type of Grout � Irrigation 1 3QApprox. De th ❑ Eastern Surface Seal Installed by Repair Work Done C1 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter _— Sealing Material (top 50') Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic stem i p y permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial__ Other Number of living units: I Number of bedrooms t Character of soil to a depth of 3 feet:I ' Water table depth SEPTIC TANK ❑ Type/Mfg; Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to dearest: Well Foundation Property Line ' I LEACHING LINE ❑ No. & Length of lines Total length/size !f 1 f FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 I SEEPAGE PITS ❑ Depth Sizei Number SUMPS ❑ Distance to nearest: - Well Foundation -Pro party-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 t 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.R1111561 for II it inspections. Complete drawing an reArse side. Signed Title: Date: �� Z !�� x FORT DEPARTMENT USE ONLY r)_J Application Accepted by Date " 00 Area r) Pit or Grout Ins ction b I Pe Y ate Final lnspectian by Date Additional Comments: ❑ Stk 466-6781 1 ❑ Lodi 369-3621 ❑ Manteca 823- 104 0 Tracy 835-6385 ,n„ __ „ Applicant- Return all copies to: Environmental Health PermitlServitxis 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 1r`� FEE AMOUNT DUE ( AMOUNT REMITTED CKIF RECEIVED BY D INFO ATE PERMIT'N0. / CASH + EH 13-24 iREV-1/e5Y EH 14-2e 4