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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT t i 1601 E. }HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) 1 � 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. . 'k . Job Address .4! City Lot Size M D071-? Owner's Name .��r i�Cll2 ' r� re's 103 /V c list . z Phone Contractor r .5 Address S se No. OV61/3 Phone_6 c%'/t/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK /76X f:!_, SEWER LINES DISPOSAL FLD. P 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private �i(Gravel Pack Tracy Type of Casing00yC.1 Specifications l'l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grou J E I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump I H,P. State Work Done_ 1 Well Destruction ❑ Well Diameter l Sealing Material (top 50') i Depth — � Filler Material {gelow 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION 1 I DESTRUCTION { I (No septic system permitted if public sewer is 1 'I available within 200 feet.) rn Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms e Character of soil to a depth of 3 feet: Water table depth rn SEPTIC TANK ❑ Type/Mfg Capacity �-No. Compartments PKG. TREATMENT PLT. ❑ _ Method of Disposal I Distance to nearest: Well Foundation Property Line Imo ' LEACHING LINE ❑ No. & Length of fines Total length/size `� FILTER BED ❑ Distance to Barest: Well Foundation Property Line I l SEEPAGE PITS I 1 Depth i Size _ Number SUMPS Ll 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 pefmit 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 applicant m st call for.all r wired ' spections. Complete drawing on rev rse sid Signed X Title: Date: �.—y— IF EPARTMENT USE ONLY Application Accepted by Date Area t Pit or Grout Inspection by D to Final Inspection by pate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 QVIrracy, 1335-638 Applican}- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 &7 ` r,� - �-�. �@ �s' . � �so /U��0 - Pu fwsrtud . Twp � c va-I,re s. ^J o tcCe s CK 4 INFO FEE MOUNT DUE AMOUNT REMITTED CASH) RECEIVED BY tttD��ATE / (PyERMIT'NO. i ♦ EH13-241REV. EH 114-26 1/951 nfoL l•/ /�' Gt �f LLL 'U/ / VVV �i ((�� } 3/26- C-m-f• 411 /off,cJ e:7�� s*"d, er^k4t4s space _ il/a) — 46vu��F