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APPLICATION FOR PERMIT 9'5CO-'SAN JOAQUIN LOCAL HEALTH DISTRICTXMEPIT (� ��` RECEIVED 0 1601 E. HAZELTON AVE., STOCKTON, CA L �� YOG�`��P v,<. Telephone (209) 466-6781 DEC 14 1938 PERMIT EXPIRES 1 YEAR FROM DA E ISSUED N4 �,CJ ��.� (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein de sLG ITk5E"ICF9n 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 Districct./1 N� , p� f��r Job Address m/ v w�• Ate,._ zr� City 5ror,6�� Lot Size PM Owner's Name _1J�L� � Address Gpryulvnu�A /��%�T. 'sr /rTF;a wrrFG LAS! �� Contractor ! Address 'jPlf� fG 9 iiJ` License No.�`3y3SPhone � � ,� TYPE OF WELL/PUMP: — NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OT ER E) DISTANCE TO NEAREST: SEPTIC TANK f— SEWER LINES �� DISPOSAL FLD. PROP. LINE t FOUNDATION 5Q/Z AGRICULTURE WELL OTHER WELL PITS/SUMPS'A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r1:0:2_ Dia. of Well Casing 21,z— ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing prZ _ U,05Z�)t/L. Specifications __ ('1 Public,��pry(�n /�tA Other 3Ur� 1 1 Delta Depth of Grout Seal ?'�7 Type of Grout O I I Irrigation J7_0i Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done 17 Type of Pump H.P. ___ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth _ Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I I HI PAllt,AUDITION I I DESTRUCTION I I (No septic systern permitted if public sewer is available within 200 feet.) 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 ❑ 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 I Depth Size — Number SUMPS l I Distance to nearest: Well Foundation ___ Property Line DISPOSAL PONDS Il 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 become subject to workman's compensation 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 iyJs t�i,I�1RI}yDR�ypeWytqLs4f11apIL wo�r`fp�ili>4giTlpensa tion laws'of Californ' FNVIPONMeN IAL HF ALfH OIVI 'ON The applicant st all for allo tions. to drawing on reverse side. ECI.4 L PERAMI Signed Title: ICA��_/a � GG r�C�--� Date: 1 --- FOR DEPARTMENT USE ONLY Application Accepted by _ —_— — Date c1_ Area Pit or Grout Inspection by D •, ___ Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH 1' a EH 1324(REV.),n., t I��. �- 1/ f.! q EH 1426 . ^: °'�S� 1 6