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APPLICATION FOR PERMIT SAN JOAQUIN.LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 11 y Telephone (209) 466-6781 PERMIT EXPIRES 1,YEAR FROM DATE ISSUED (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 IItgo �" r t,(-Rn1_12 84 City LODl Lot Size '!16 "e-ee-Z PM Owner's Name R O n M&—&—4,Ct4L i V Address 11617 � � ?"+�" Phone Contractor IL, -—5,9115 Address 1 1_3,(A .N License No.. Phone TYPE OF WELL/PUMP: NEIN WELL WFIl WELL REPLACEMENT DESTRUCTION 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE "49 FOUNDATION AGRICULTURE WELL OTHER WELL—PITS/SUMPS _ INTENDED USE T PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �d �� rf ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Pia. of Well Casing ❑ Domestic/Private O'G.ravel Pack ❑ Tracy Type of Casing ?OneL Specifications r I'1 Public Cl Other 171 Delta Depth of Grout Sea! D Type of Grout 1 _se Irrigation . 26—O.Approx. Depth I I Eastern Surface Seal Installed lay _ Repair Work.Done [3 Type of Pump H.P. State Work Done Well Destruction ❑ Welt Diameter Sealing Material /top 50'1 Q, Depth x Filler Material 18elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION { I DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence— Commercial_ Other �l 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ J 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. Home owner or licensed agent's signature certifies the following: "I conify.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 California."Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." The applicant must yll for all required in ctions. Complete drawing on reversg siQde�. / q Signed X Title. _. �EC�iyt _.._. W Date: /9 1 y— ` FOR DEPARTMENT USE ONLY ApplDGroul cepted by Date (�1 `/ Area J Pit ospectionby t � __ -- Data 'T- p Final In-spec ion by j' —,__. Date Additional Comments: IV _11� "Jo4 : ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 c3Tracy 835-6385 Applicant"- Return all copies to: Environmental Health Permit/Services 160.1 E. Hazelton Ave., P.O. Box 2009,--Stk:; EA 45201FEE INFO AMOUNT DUE AMOUNT REMITTED ASHCK RECEIVED BY DATE PERMIT'NO. + EH 13-24 IREV,t In 51 -70 EH 14,29 �✓ (�