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r I l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZE T ON AVE., STOCKTON, CA f Telephone (209) 466-6781 f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (Complete in Triplicate) 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 Job Address [L TZ.h�2 /�P(� City L-0JOi. Lot Size_ � � PM f i Owner's Name Ron me h A111/I" Address 7 7 !: r Phone t36 = 02 Contractor Addres 11 G _Licerise_iVo��z73(9_01y_ Phone-7Y 22 7 ' TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑' T ~ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ # DISTANCE TO NEAREST:; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE d j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUINPS) r— s r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial _ + Operi Bottom El Manteca Manteca Dia. of Well Excavation { Dia. of Well Casin .I`1, Ll Domestic/Private� Ca vet Pack El Tracy Type of Casing 6Tee.L Specifications ; �kT �s } M Public ?*I- Other _ I IJDelta Depth of Grout Seal A90 Type of Grout _ Irrigation F ..Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work.Done _7' Type of Pump H.P. State Work Dane • Well Destruction ❑ Well Diameter Sealing Material (top 501 + r , ' Depth r• Filler Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) i Installationwill serve: Residence Commercial_ Other 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 I r i LEACHING LINE ❑ No. & Length of lines Total length/size\' FILTER BED ❑ Distance to nearest: Well Foundation Property Line 9 SEEPAGE PITS I I Depth Size Number SUMPS i ❑ 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 Joaquiri Local Health Dp%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$hall 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 applicant must yol for all required in ctions. Complete drawing on reversgside. Signed X Title: Date: T'1 / _ 7C2 1 I f FOR DEPARTMENT USE ONLY !J r Applicat' Accepted by Date �J Area c� Pito Grout inspection by aZ�� ` �-t`� ' Date `t 5 Final Inspec ion byi Date Additional Comments: all, ❑ Stk 466-6781 - ❑ Lodi 369-3621 ❑ Manteca 823-7104 EfTracy 835-6385 CC1�tJcf u— � ' �5 3 Applicant turn'all copies to: Environmental Health Permit/Services-160,1-E:-Hazelton rove-Ave -Box-2009;-Stk.-, GA-9520.__ + r FEE AMOUNT DUE ��AMOUNT'REMITTED CK f_"RECEIVED BY DATE PERMIT'NO. I INFO 'CASH ->��_ �.EH 13-24 MEV. +� EH 14-28 �" J i