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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED f 1601 E. HAZE T ON AVE., STOCKTON, CA OCT 2 4 19$9 Telephone (209) 466-6781 rf�� I; DN MENTAL HEALTH PERMIT EXPIRES ]'YEAR FROM DATE ISSUED< D (Complete in Triplicate) ERv,%W Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �'I/7T�-q/ I Job Address 1r;/r///r� 2Fpdy'a c�F� City c7V��x_ Lot Size PM Owner's Name A P pP1111f1C7 S' .E-ChMC/>FL� 9 "�`�r�/11�� //e. �f/ :. /hone i J 1 Contractor C ALGl!A_[W- -DJe)W&6kddress icense No.,, 2&$-2 Phone_ — TYPE OF WELL/PUMP: NEW WELL D6, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ` DISTANCE TO NEAREST: SEPTIC TANK _1 SEWER LINES 3GYJPT' DISPOSAL FLD.' PROP. LINE , l FOUNDATION AGRICULTURE WELL OTHER WELL-.—' PITS/SUMPS—=— INTENDED ITS/SUMPS —INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IA-Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Exc�a�4.6on Dia. of Well Casing ❑ Domestic/Private �Gravel Pack ❑ Tracy Type of Casing f9'_J775SL Specifications ❑ Public 1-1 Other 5JV*VN Depth of Grout Seal Zf s51— Type of GroutQj!JW I i Irrigation L.Q#FvFprox. Depth i 1 Eastern Surface Seal Installed'by- Repair Work Done ❑ Type of Pump H.P, State Work Done_ t" 0 I Well Destruction ❑ Well Diameter Sealing Material (top 50') e� Depth Filler Material (Below 501 __ Q TYPE OF SEPTIC WORK: NEW INSTALLATION €7 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is . — a available within 200 feet.) n r 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 K SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �PKG. TREATMENT PLT. ❑ Method of Disposal -+C Distance to nearest: Well Foundation Property Line �1 LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t SEEPAGE PITS I I Depth Size Number SUMPS ❑ 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 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 Califor.nia." Contractor's hiring or sub-contracting signature certifies the following: "Ic rtify 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 applica us II r all re ed inspections. Complete drawing on r rse sid r �� Signed X Title: Date: d i F R DEPARTIMENT US NLY Application Accepted by Date J0, `�� Area IS— Pit � �3 j Pit or Grout Inspection by Date Final Inspection by Date l2 Additional Comments: �2 ` ❑ Stk 466-6781 Cl Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave.,IP.O. Box 2009, Stk., CA 95201 l'Zp ` G e l {CA,FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.t/m 5) �q EH 14-2a —Z 7 4 y-2&b9 I