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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JWi 71r' 194,8 <br /> (Complete in Triplicate) yyAt�'�va0NME111 HEAL <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install tfAfI rk�gpjR�l�E�is application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rula a lations of the San Joaquin <br /> Local Health District. zz�� �7 ,,r n <br /> Job Address ���"7 L4 4 P1` " S H 1 'y C /l V � ' City STUC tz l f9i Size PM <br /> {{ 12vc> S'H;T+f Si, SctitE loS'� / <br /> Owner's Name TC><r_)� Co. US Address UVUSTX' N ; Tx -77002. Pho4-t <br /> MLHAUG C- 5-7 <br /> Contractor 1676 RISDON ROADLicense No. 9Se?390 Phone 4!!S"66 <br /> TYPE OF WELL/PUMP: NEW WELLAtltlres WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ElOTHER Cl1 <br /> DISTANCE TO NEAREST: SEPTIC TANK —� SEWER LINES 30 DISPOSAL FLD. PROP. LINE 1O <br /> FOUNDATION AGRICULTURE WELL OTHER WELLio PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 <br /> C1 Industrial D pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ElDomstic/Private Gravel Pack ❑ Tracy Type of Casing Specifications7l- <br /> M Public Ll Other f7 Delta Depth of Grout Seal S Type of Grout C­-E'4'"�-s^^ t <br /> XffpO�lI r rg�Tt�igDJ (I�I —Approx. Depth I I Eastern Surface Seat Installed by GON7—r—l"Tua _ <br /> �Reirt Work Donfe U Type of Pump H.P. State Work Done_ <br /> Well Destruction Well Diameter Sealing Material (top 50'1 <br /> Depth .?GJ I Filler Material IBelow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) — <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: _ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING INE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I he"prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> 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- <br /> tion laws of California." <br /> The applicant t call fo/r 411 inspections. Complete drawing anyrey/��rae side. / (' <br /> Signed X_ Date: i5 <br /> n LR DEPARTMENT USE ONLY <br /> Application Accepted by b Date 2 tZ I ISa' Arca <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6'185 <br /> Applicant - Return all copies to: Environmental Health Permit/ServicesC1�601 E. Hazelton Ave., P.O. Bos 1009, Stk., CA 96201 <br /> 1 +. <br /> FEE I <br /> ev.cvo..<1,r,6..� `+ ,.e„o�...ble: ..✓..,:+s o., le.. <br /> INFO AMOUNT DUE OUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT'NO. <br /> � _ <br />