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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT l.as 1; IVIAdS 1601 E. HAZEL T ON AVE., STOCKTON, CA `'1015UII❑ H11V3H 1V1N3WN0211AN3 Telophohe (209) 466-6781 YJ07 N111C >Ji"() ��nIT EXPIRES i YEAR FROM DATE ISSUED SSP �1 1�� (Complete in Triplicate) \\11�hTes 4��livlt� Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or installlihe " .made in compliance with San Joaquin County Ordinance No. 549 for sewa a or No. 1862 for well/ um and the (��5' �� This application is Local Health District.t e`/ g p P and Regulations of the San Joaquin W'e.J^,�/PSL /+6 Job Address /2-6 ' r r (; /JJQ4Z7 > riV'41Z., w` / City �i OTL. Lot Size PM ,Y Owner's Name iQk61'OC�l7 /�}6lilvt2lJ.rO4 Aad ess 0,0. 130X 30 1 t7 Sgq-v.2 0,J.-_� }''� p/ Phone Contractors I`+�J-E� LJ�'i<`f,fl!d�} Address ��j p ,� �� / �I�� License Na?�3'�D'S p�Q es� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ A� �•- PUMP INSTALLATION ❑ SYSTEM REPAIR C1OTHER1XMo6 fflrf'f D Well DISTANCE TO NEAREST: SEPTIC TANK --�650 SEWER LINES �"5D DISPOSAL FLD. NA PROP. LINE ..FOUNDATION >.SO AGRICULTURE WELL OTHER WELL /YA PITS/SUMPS NA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation yr ❑ Domestic/Private ❑ Grave! Pack F1 Tracy Typo of Casin g p Y� Dia. of Well Casing -/11CR Specifications )� (1 Fabric [ 1 Oth r �� ❑ Delta Depth of Grout Seal 220 0 '1 /nelyt Pett' g �a,��o Type of Grout I I Irrigation 3,__- pprox. Depth I I Eastern Surface Seal Installed b t Repair Work Done_ ❑ Type of Pump H.p. y -o rk - State Work Done , Well Destruction ❑ Well Diameter Sealing Material (top 50') ---Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I k (No septic system permitted it public sewer is Installation will serve: Residence— Commercial_ Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 1 SEPTIC TANK Water table depth ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: 7,Wpll Foundation Property Line LEACHING LINE ❑ No. & Length of lines F FILTER 8E0 Total length/size r ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i l Depth Size s Number � SUMPS ❑ Distance to nearest: Well Foundation Line s DISPOSAL PONDS ❑ Property - 1 hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and i 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 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 hiringor sub-contracting signature I 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 /call �for all required inspections. Complete drawing on reverse side. v Signed.X 0 .�— Title: ' i �/ a� S /�SL3/}' 7�/}�`�Date: KPRNT USE ONLYApplication Accepted by6��/ Date '� �/ reaPit or rout nspection by Q" Date Final Inspection by� Date Additional Comments: ❑ Stk 4636-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952171 FEE AMOUNT DUE AMOUNT REMITTED K INFO RECEIVED BY DATE PERMIT"ND. r.EH 13-24(REV.i n 51 EH 14-28 191 O ��.. .rd <� t 111111 i APT IS S /f, FC3i7 S' '{3rp., C w,,)er is Oer1/_S �4'/�am�nt.4#/irfin,D