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s - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT " ` 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 I. PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) 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. n } � i Job Address �0 94rAe- City LlAdfA Lot Size PM q Owner's Name t '-Veal CA4 Address Q �"�' �T�' 46�4t' 0 L4 Aldt,-) Phone } u rfP License No. 97 / � Phone_ Cont �"�"�""�—'—,�" _Address TYPE OF WELL/PUMP: NEW WELL )L WELL REPLACEMENT ❑ DESTRUCTION D PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE k FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS C> f INTENDED USE TYPE OF WELL PROBLEM-AREA CONSTRUCTIOW SPECIFICATIONS �! ❑ Industrial X Open Bottom ❑ Manteca r Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private B-,Gravel.,Pack El Tracy Type 0 CasingkS Specifications &DO x•9 3 ❑ Public ❑I.Other ❑ Delta Depth of Grout Seal ; Type o1 Grout *.Irrigation 530 -Approx. Depth "'�i I Eastern Sutr facdSeal Installed fly'"� Repair Work Done El Type of Pump by ►y._ H,P. /94, 1 State Work Done-dgttK��d D_� (1Q if Well Destruction ❑ Weil Diameter Sealing Material Stop 501 Depth Filler Materia) (Below 50') TYPE.OF-SEPTIC WORK-;—NEW_INST.ALLATION Ia REPAIR/ADDITION LI DESTRUCTION l 1 Wo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other -' t �`. Number of living units: !" Number of bedrooms j r .: .. .� l Character of soil to a depth of 3 \ton ; �Water-table"depth SEPTIC TANK ❑ ;;Type Capacity —No. Compartments PKG. TREATMENT PLT. ❑ ,y1.1 two #.. !Method of Disposal 1 I'Distast: Well Foundation Property Line LEACHING LINE ❑ No. & Length of II es Total lengthlsize l FILTER BED CI ;Distance to nearest: Well Foundation Property;Line I SEEPAGE PITS 11 Depth Size Number SUMPS L-1 " Distance to nearest: Well Foundation Property'Line f 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 DiMtict. 1 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." Thepplicant m �scall fo all r uir inspections. Cognplete drawing on verse side Signed Titla: Date: FOR DEPARTMENT USE ONLY it Application Accepted by Dates �� ` Area Pit or Grout Inspection by Date Final Inspection by Dateo/_ '_ 99t r Additional Comments: ❑ Stk 466-6781 C7 Lodi 369-3621 © Manteca 8.23-7104 ❑ Tracy 835-6395 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 AMP M •I FEE AMOUNT DUE AMOUNT R ITTED I CA R RECEIVED BY DATE PERMIT NO. k INFO t +.EH 13.241REV.t/n51 �� P/ `/r/�CO` I EH 14-2s Oc `1 J / I