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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT !' 1601 E. FIAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781cs + r T�� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 10. y � Application is hereby made to the San'Joaquin Local Health District for a permit to construct and/or it46 rk` 5�i ,,�sibed. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pulations of the San Joaquin Local Health District. Job Address'SA'V L_ 14_/!t-A71A4-7y®o �W elf-4W4,' Zv City K k-77 I/Lot Size PM Owner's NameAddress G V /k/ Phone ' "�3 Contractor_ (iVi �i?Tz°rIAddress /� r a /[- ""+� Qf�K+�e-,TFT,eca C.�T License NoVOl337 Phone 3O�p4 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONK SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC T N t ,--ff �8 Tndustrial 11g Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casin ❑ Domestic/Private -.-�ra-vve-ll Pack ❑ Tracy Type of Casing f�L Specifications 1-1 Public tether f l l Delta Depth of Grout Seal `"' Type of Grout G��'u 7— I ( Irrigation Appro�x Depth l I Eastern Surfa a Seal Installed by /9� Repair Work Done ❑ Type of Pumper �y� H.P. 2 State Work Done I Well Destruction ❑ Well Diameter Sealing aterial (top 50'1 Depth IFiller Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION l,l REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is rI available within 200 feet.) 7 Installation will serve: Residence— Commercial.— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet! Water table depth v� C SEPTIC TANK IDType/MfgI Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line li a i SEEPAGE PITS l I Depth Size Number I SUMPS L1 Distance to nearest: Well Foundation Property Line �. DISPOSAL PONDS ❑ A Is 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 Di?;trict. 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 tfie performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." I The applicant call for rear inspections. Complete drawing on reverse sr e. r c(fit Signed X Title: IraCp )N I'FA�SJt DEPARTMENT US ONLY S <VML l`1M Application Accepted byC '1 -r "v Date Area rQ Pit or Grout Inspection byDate Final Inspection by nT Date Additional Comments: /1�Q�'[{(lJ(rf f��O L !' ❑ Stk 466-6781 ❑ Lodi 369-3621 b Manteca 823-7104 ❑ Tracy -635-6385 Applicant- Return all copies to: Envirorimental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE Ir INFO AMOUNT DUE'r' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH1 3-241REV.i/H51 _e 1 �350D �y,�s [ 3-341 EH 1428