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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,}STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES 1,Y EAR`FROM',DATE 'ISSUE Dr' (Complete in Trliphcate) 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 Ryles and Regulations of the San Joaquin Local Health District. i W. Job Address 20415 E Hwy 26i"' `" G City' Linden Lot Size PM' mit = Owner's Name Lloyd Potter. Address=. 20415.,_E. H _-26 " Phone � 1 Contractor Address P. O. BOX 64License No^377923 Phone 887-3554 ; TYPE.OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ " PUMP INSTALLATION 9 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ► FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS { .; ` f INTENDED USES. TYPE OF WELL 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS l ❑ Industrial _ ❑ Open Bottom O Mantecaf �,Dia-of Well Excavation Dia, of Well Casing ❑ Domestic/Private 4 A_rc❑ Gravel PSack ❑ Tracy ` Type of Casing Specifications I ❑ Public ❑ Other }❑ Delta Depth of Grout,Seal- Type of Grout ❑ Irrigation —Approx. Depth El Eastern Surface Seal Installed by _ 4� Repair Work Done ❑ Type of Pump sub H.P. 3/4 hp A\ (•''-'State Work Done PUMP installed Well Destruction ❑; Well Diameter Sealing M aerial (top 50'1 `^ •`€- ..„;1. gee, _ -j Depth—J 1'�l�: ' t 1. t F!I r Material (Below 50',1 j TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION:.❑t DESTRUCTION ❑ (No septic system permitted if public sewer is _ ,, `.+ R,,,,„, ,.Favailabl_e-within.200_feet.).- Installation will server 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 j PKG. TREATMENT PLT. ❑ Method of Disposal j 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 SEEPAGE PITS ❑ Depth ' P Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PQNDS ❑ , ¢ I hereby certify that I have prepared this application and that the work will be done iri accordance with'Saii 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 performarice 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." The applic ust call for Il d inspections. Complete drawing on reverse side. Signed TitW President Date: 2I.4l$7 FOR DEPARTMENT USE ONLY _ /� r Application Accepted bLL Date Q�-'7� / _ Area Pit or Grout Inspection y Date Final Inspection by Date Additional Comments: - EQ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,Stk.-, CA 95201 --1 FEE AMOUNT DUE AMOUNT REMITTEp RECEIVED BY DATE PERMIT NO. INFO "� EH 13-24 + EH 14,26IREV.r/e 51 .. d n _ '-L7�,� %7