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APPLICATION FOR PERMIT PAYMENt i SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZELTON AVE., STOCKTON, CA JUN ��Or Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSU!�NV��N�EALTH r (CO [JN�YS I Application is hereby made to the San Joaquin Local Health District for a per� aw cribed. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or N 18&2 for well/ umpulations of the San Joaquin i Local Health District. 5pE� Job Address ^Ts SYS 1 441- City �T Lot Size Owner's Name ��lel! ©l d (a Address Q UiAk U23. GA�Phone -:..N- LI 'I !t4:( /; �Contractore Address GtUO,r 61�q License No, �t5' s Phane G�GJ2S~�Z� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER�! 3 iv�Ol�t+'It lh cuc IlS DISTANCE TO NEAREST: SEPTIC TANK V _. p—� SEWER LINES ..-- DISPOSAL FLD. PROP. LINE �E' FOUNDATION AGRICULTURE WELL Nom_ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial L1Open Bottom ❑ Manteca Dia. of Well Excavation_10 t S Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack �,,, p� ❑ Tracy Type of Casing Specifications f'] Public Other 1tM1O ,+i"J Cl Delta Depth of Grout Seal ff-- Type of Grout I I Irrigation _._Approx.!Depth LI Eastern Surface Seal Installed by 4E]{S+ 147e2___.H-_, t, Repair Work Done ❑ Type of Pump Ktf4 H,P. State Work Done Well Destruction ❑ Well Diameter 16 kdeLS— Sealing Material {top 50 X )in bKr4�arin Depth (26 Filler Material IBelow 50') -- TYPE OF SEPTICWORK: NEW INSTALLATION I'] REPAIR/ADDITION f I 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 1 Character of soil to a depth of 3 feet: Water table depth �-•� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments LJ PKG. TREATMENT PLT. ❑ d Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size I ` FILTER BED ❑ Distance'to nearest Well Foundation Property Line SEEPAGE PITS l I Depth Size Number l SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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, nd rules and regulations of the San Joaquin Local Health District. 1 Home owner or licensed agent's signature certifies the fallowing: "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 tri 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." ;'A (]1 The applicant call for all rqq fired ctions. Complete drawing on rev rse side. 11 Signed X Title: r`i a~ �5 Date: FOR DEPARTMENT USE ONLY r I Application Accepted by _ Date -7 Area I Pit or Grout Inspection by Date , I Final Inspection by Date i 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 DUE1 AMOUNT REMITTED CK RECEIVED BY DATE PERMIT�NO. INFO 1 ��+ +.EH13-24(REV.r/H5) ..7 .00 `7 'O0 1 (0(00 --21-ilb to -17011 EH 14-2a I