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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRI71=- 1601 E. HAZELTON AVE., STOCKTON, CA, Telephone (209) 466-6781 , 1 ° PERMIT EXPIRES.1 YEAR FROM DATE'ISSUED. ' l4' ,r :L..,t. 0 r, (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.649 for sewage.or No.1862 for well/:pump and the Rules and Regulations.of the San Joaquin Local HealthDistrict , :r a' i:;•.Y f113 Sit 'm Job Address ZaA Clty,e W_ Lot Size �/ 'C--its PM Ownef's Name 4jU42ff&M2 G! W's ZTX) Address .D •1��X �� Phormte° fC� Contractor's Ne a License No. S KP�� ' LS: I Phone TYPE OF WELL/PUMP: NEW WELL 10. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR 0 OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK�(J�_ S9WEft LINES 10062€ DISPOSAL FU).&17Xj_ PROP, LINE 300 FOUNDATION ]!? ^AGRICULTURE WELL'_ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Ubwation bia-af Well Casing p ll Domestic/Privatekf Gravel Pack q Tracy Type of Casing Specifcatipns !� C] Public ❑ Other in Delta Depth of Grout Seal _ Type of Gro ❑ Irrigatibn -- ApproxsDepth ❑ Eastern' Surface Seal Installed by y Repair Work bone ❑ Type of Pumpm H.P. State Work Done Well Destruction ❑ Well Diameterl� Seal•7nq Material(top 50') f. Depth _ T 1" ` ' ' _ Filler Material(Below 501-- TYPE OF SEPTIC WORK. NEW INSTALLATION ❑ REPAIRIADDITION❑ DESTRUCTION ❑ (No septic system,permitted if publ G sewer is f jj available within 200 feet.) Installation will serve: Residents 1 Commercial_ Other iJ _ Number of living units: Number of bedrooms i Character of soil to a depth-of 3 feet: L'* -_ �' �' _ 'Water table depth SEPTIC TANK ❑ Type/Mfg fix. Capacity—1 No. Compartments PKG. TREATMENT PLT.❑ � ; f1t `Method of Disposal Distance to nearest: Well Foundation Property Lina - rq — �LEACHING LINE ❑ No. $ Length of fines f s t x'�• Total length/size FILTER BED ❑ Distance to nearest: Wpll �" Foundation Prop&ty Line N SEEPAGE PITS ❑ Depth Size ,..I - Number' ,..� SUMPS t ❑ Distance to nearest: Well Foundation Properly Una_ r 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. 1. ,„„V' / 1. .I Home owner or licensed agent's signature certifies the following: "I cerdWthat 16-the performance of the work for which this parmh Is issued,I shall not employ any person in such manner as to become Subject to workman's cam minsatlon 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,1 shall employ persons subject to workman's compensa- tion laws of Cel'rforfi1Et , The applies call for all required inspections. Compi. drawl g on reverse aide. Signed Xe itle:__ Date: m „ FOR DEPARTMENT USE ONLY Application Accepted by r"r� Data A Area_ f� Pit or Grout Inspection by M' Data Firtal inspection by Date J m � �, 1 // > �•l�vY I 1 Additional Comments: _6��r�Yr.�tGL ( '��I�rju�dvy l✓�►-m�liby� fYW- ��'.t� 01 f4�hd� �I.�b�iu`rJ'Y r 1t . .0 D Stk 466 781 r❑ Lodi 369-3821 -0 Manteca 823.7104 ❑Tracy 835.6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,'P.O. Box 2009, Stk., CA 55201 FEE INFO, AMOUNT pUE AhfOVNT REMiTTEO 1. G4SH RECEIVER BY - DAT€ PERMIT"N0. , + EH 73-24IgEV.101231ISs- . EH 14-29 V .. .