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I . APPLICATION FOR PERMIT SAN JOAQU'IN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZE`T ON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6761 r� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APR 13 1981 (Complete in Triplicate) ENVIR �' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor NM NTt df1�t4t. lication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rul� the San Joaquin Local Health District. NO Job Address I Z Sb Sa - LJ lS .N OAX City T-'�"W�N Lot Size PM Owner's Name �1 t'-t/ Address IS-75'n Al e!lz f bII>}JV Phon-(3 �r_/� or _ 4S AAt ��s� t f ► q rz r ContractorDL i4XA-6 F_ Iy Address�7qt) 4!5& �'T '5•� �521_iceasI No. 17 Phoned 27-7- o' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ejiP/2/Iye-S , DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS S INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 5:Qa2 C - f . P_ f ccs+.s ❑ Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing L] Domesticl Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ['1 Public ❑ Other ❑ Delta Depth of Grout Seat Type of Grout —_ I I Irrigation .Approx. Depth I I Eastern Surface Seal Installed by µsl Repair Work Done 17 Type of Pump H,P. State Work Done d/� / Well Destruction ❑ Well Diameter Sealing Material (top 50') _ 54.c- re-, Depth Filler Material (Below 50'1 ✓ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (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 C1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK L) Type lMfg Capacity No. Compartments LA PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ^ LEACHING LINE CI No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size ee Number 6 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 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 follow' . "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compens tion laws of C orn' The appli t call f r )red i omplete drawing onside. Signed X Title. i> � L�l/f Date: FOR DEPARTMENT USE ONLY 7 r, Application Accepted by �rr,.`r s�L�' v �. Date �l� ;-e"tf'? Area Pit or Grout Inspection by / Date Final Inspection by Date Additional Comments: Spae !r1't .t3G C2 6t4�J "'k-eal I4 ❑ Stk 466-6781 ❑ Lodi 369-39'21 ❑ Manteca 823-7104 ❑ Tracy 835-685 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMI7'NO. INFO CASH EH + EH 13-24 IREV.t n 57 EH )436 _l C) C7� 1_V1�L9 [[ r