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i . APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r- 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUEDC IV^ a 7. (Complete in Triplicate) ��C �1D Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the ��frrein descnbr Q/�jpplication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules 5ff19(Ft�g iations ofnaan Joaquin Local Health District. —!'Vy Job Address60N - - o8d-52 ; 5 ,✓ p�RMI T�ER�i yFALP �1 A -ty Lot Size Cann�_ -1r,°fJJf�vi ! Kew�{ �i Oy 4„h Orn i _ /A i Owner's Name „ >P Address ��,LJ "I 1fiT�_W� ?G Phone Contractor G!/rn Address ZS2S,E. / �f�7-ttiC License No. 6,ZZ& Y Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ , PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER I &&FOT- c L-f DISTANCE.TO NEAREST:.SEPTIC TANK- SEWER LINES DISPOSAL FLO. PROP.-LINE FOUNDATION AGRICULTURE WELL OTHER i WELL PITS/SUMPS r _lot INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Ria- of Well Excavation UL Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ("1 Public ❑ Other Ll Delta Depth of Grout Seal p� Type of Gr ut I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by ( 4rPr LV 1 _ Repair Work Done L7 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') II �r1 I Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION f I DESTRUCTION i I '(Na septic system permitted if public sewer is ;available within 200 feet.) Installation will serve: Residence_ Commercial— Other ' I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ��' Water table depth '. SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line t II �f LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation `Property Line I,. . d SEEPAGE PITS I I Depth Size Numbe: —SUMPS'' � — L-I Distance to-nearest: - Well —Foundation— "Property L"ine DISPOSAL PONDS ❑ if 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." Ii The applica u t call for all required inspections. Complete drawing on reverse side. li �L Signed X Title: /I'/g'1.. I _ pate: `61 FOR DEPARTMENT USE ONLY Application Accepted by Date 11,2 /7-fo Area Pit or Grout Inspection by Date Final Inspection by I Date 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 j II ; FEE u INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY'T DATE PERMIT'NO. i + EH 1324(REV.rin5) LOW EH 10-2a (� (J