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APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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. TMs 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. we// /Y?-23 - Job Address eJ� La�coRs Acce55 Rd at Acacia St, city Lot Size UV✓1.��1O7.Eirv. PM ,, � �,�py�� 5 N, (;clrlma. Auz.;Rl n hone 9q.- 2 ,a8 Owner's Name G L Address /"' Phone Contractor — Fe Contractor TR.C�.5CV7 , C/9 License No.S'72S�oZ Phone Address TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION- 11 SYSTEM REPAIR ❑ OTHER)?fMO0if0'4nq Wel( DISTANCE TO NEAREST: SEPTIC TANK N A SEWER LINES >SO/ DISPOSAL FLD>-TO/ PROP. LINE -> O FOUNDATION /'J/A AGRICULTURE WELL AIM OTHER WELL?50' PITS/SUMPS JS0 / INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation— —//1 Dia. of Well Casing J!-/� "/n ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing PVC Specifications �'/q/ap� 11 Public ❑ Oth11er/1 n Delta Depth of Grout Seal I / 130 /00 Type of GrourcemQ�-. Irrigation Z�j 15f_AP9imx. Depth I I Eastern Surface Seal Installed b, a_-TC'Ch- �("/II/r'15L _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system 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. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cer.ity that I have prepared this application and the: the work will be done kr accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Lccal Health District. Home owner or licensed agent's signature certifies the foiiowing: '9 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 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. nn Signed R, �' � R. G, Title:iQ e//Ca4lt5/I.QQ1'Y U�-(Date: —/o/z z, /I,,. ' , ��F,D�I DEPARTMENT USE ONLY �f Application Accepted by VYv �• �' ( u�""'z Date v Area . D. �� Pit or Grout Inspection by A�VSIUt�/�Lv�(b` -w, Date/ r Z Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-&185 Applicant - Return all copies to: Environmental Health Perm't/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ApphCa� �'s rlea Qcurra C`o.; otL)O-01r C-t Ra' (�- 477C(Clzec(07wm yct FEEINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH T}24 IREV.I,n � C�I /t • 1 J 7V51 EH I M rU