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>t f APPLICATION FOR PERMIT SAN JOAQUIN.LOCAL HEALTH DISTRICT V� 1601 E. HAZEL T ON AVE., STOCKTON, CA f, 0-Y Telephone (209) 466-6781 t.- 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 Ordinanco No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r /� Job Address /19 o t.4/ 4-,it 1'd City LojoLot Size 6 «� PM Owner's Name r ,Q R m�11rc�CL-P,u Address 1147 7 N fJe- IA'e_5 A Phone Contractor (r6c?! 5 .4--Sc.7175 Address . N j_icense No.. X73 O y Phone -11 - 22 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE T PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d O Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic%Private O Gravel Pack ❑ Tracy Type of Casing eeL Specifications ` f 1 Public fl Other n Delta Depth of Grout Seal D Type of Grout 7!.-rXn�_ Irrigation . 9.,W-Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work.Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'I Q Depth I Filler Material 18elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) r Installation will 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 O Type/Mfg Capacity No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 . . 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 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 biome 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,I shall employ persons subject to workman's compensa- tion laws of California." Theapplicant must 11 for a!1 required in actions. Complete drawing on reverW side. Signed X Title: Date. L/9 —/Y- FOR /9 -1Y-FOR DEPARTMENT USE ONLY Applica' Accepted by Date f 0 % ! y Area f Pit o Grout pection by t�"� - . Data � Final Inspec ion by"j-!)'�<<�-.-- Date / Additional Comments; C/r f✓ �X-D L r O Stk 466-6781 O Lodi 369-3621 O Manteca 823-7104 Tracy 835-6385 '-Ur-,coo t,- �—ef_ �55� Applicant- deturn all copies to: Environmental Health Permit/Services 160.1 E. Hazelton Ave., P.O. Box 200g,--Stk., EA 95201 "�wQ( FEE INFO AMOUNT DUE AMOUNT REMITTED CK V CASH RECEIVED BY DATE PERMIT'No. . EH 13-24IREV.1,1n 5) Ln �� EH 14.26