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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicatel • Application is heiaby 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.509 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ,SSQ ^ �+�^�+-� City 47A, Lot S'Ize S 0'�d-� PM Owner's Na l/hg _jA1� (�Adddress ,��S� "i�` ` _ Phone 1 Contract 1 Address ` y R&x 7&-7 License No. 3 Lj 7 Z(' Phone 3(rg'rilO S— TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ u!j �• PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ W 1 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE F 41 - FOUNDATION AGRICULTURE WELL w OTHER WELL PITS/SUMPS -- INTENDED ITS/SUMPSINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing V� ❑Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications f1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ' I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type oPPump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth .. er Material IBelp 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 EPAIR ADDITION.I DESTRUCTJON 1 I (No septic system permitted if public sawer is �f 1 available within 200 feet) Installation will serve: ResidenceComm ircial_ ot4A*'-" Number of living units: _j__ Number of rooms f T. .Character of soil to a depth of 3 feeC SEPTIC TANK - O r Type/Mtg ..r-Capacity No. Compartments .�.--� -."` .r PKG. TREATMENT PLT.L7 Method of Disposal Q`_ Distance to nearest: Well •F,oundation Property Line �_. ✓� � - LEACHING LINE O No. &Length of Iinesv Total length/site FILTER BED ❑ Distance to nears/: 4�WeN Foundation —Property Lith. !/ r SEEPAGE PITS Depth Size Number SUMPS ❑ Distance to rlearrut: Well_�00' Foundation 1 r- P_roperty Line - DISPOSAL PONDS F ❑ I hereby certity,that I have prepared this application and that the work will•bd dcWe in accordance with.San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. '.i. Home owner or licensed agent's signature certifies tha-fohowing: "I certify that in the pallormance of the work for which this permit is issued, I shall not employ any parson in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or suacontracting signature certifies the following: "I certify that in the performance of the work to Whicti this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." I / The applicant m t call for II re ued inspections. Complete clorWing on reverse side. i Signed x Tide: Date: FO`R,DEPARTMENT USE ONLY - '�y J Application Accepted by G� ,Date -/� -n lj� Arse 12- /� r Grout Inspection by Date « Z L"Final Inspection by 7=,A �d Dms,3—/ ; 2 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7100 ❑Tracy 835-M5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 v FEE AMOUNT DUE A OUNT REMITTED SH RECEIVED BY - DATE PERMIT NO. NFO j EX 1124 rKV,11"511 VX e; Lill I EM 141a