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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 22,qTelephone (209) 466-6781 lel PERMIT EXPIRES 1 YEAR FROM DATE ISSUED " e11s f)�,w!n-ll (Complete in Triplicate) M—2 2-P 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. Job Address 35q Znclustr�'� Ave- . City C�� Lot Size � PM 1 Owner's Name �ed -A ern&m d- Address --33cj Sndusfr/Cd --VZ �Phone — �� S .p(t ri fn �a eo AIM Contractor dress / CA License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ InWells PUMP INSTALLATION ❑ SYSTEM REPAIR ElOTHERX M ,f1�" 9 DISTANCE TO NEAREST: SEPTIC TANK N/-r SEWER LINES JSP DISPOSAL FLD. NA PROP. LINE >50 FOUNDATION 154' AGRICULTURE WELL�So� OTHER WELL �!5 PITS/SUMPS NA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ��❑///Open Bottom 71 Manteca Dia. of Weil Excavation Dia. of Well Casing C1 Domestic/Private yy Gravel Pack ❑ Tracy Type of Casing AVc� Specifications 5 /05 bzn f. 71 Public /�yy��y�y, 7.12 !3S Other ❑ Delta Depth of Grout Seal T of Grout Cemenfi _ I I Irrigation / ,//C Approx. Depth I I Eastern Surface Seal Installed b, _� _ 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 I1 RFPAIR/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. & 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 ❑ 1 hereby certify that 1 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 Dibtrict. 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 issued, I shall employ persons subject to workman's compensa- tion laws of California." / /O 7 l The applicant milst call for all requireeddyi�n/spectiopss. Complete drawing on reverse side. ', Signed ��r� Title:-n Ppl� 0/7 �Cr29Q/✓7�L'ueDate: OR DEPARTMENT USE ONLY Ll� Application Accepted by `(�, - Date Area `–) t{� //�� ( / Pit or Grout Inspection by �, ��-'°Date�� "K/ Final Inspection by /'!�'LiG Date I I(1 I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r e. Applicantt - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,'a.�Stk., CA 95201 1APPh0a - S /VeA,/&--nt1/SOZiL66. Tl I3 *P�E�RM72� ' ) FEAMOUNT DUE :TAMOUNT RE D EH 124(REV. /nsl OV / A SH EH I429 .00ga-19