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*" APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE,ION AVE., STOCKTON, CA ✓ Telephone (209) 466-6781 PERMIT EXPIRES 7 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 Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. JAbAddress 7 R51.11t'1r, 4,z; 122stlIdIN's POS' QZ City .�iC�C•Y:�tb� Lot,Size PM Owner's NameCi4c-V2dU ( jSY-A Address 01A t jAZ3at_ ContractorStc-,mA __k�gC.Ary- -Address 11).-T)1License No.W141113 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER JX Olw-1Tot`4 W, QeL DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE Lic> FOUNDATIONLg r i AGRICULTURE WELL OTHER WELL. PiTS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation jul Dia. of Well Casing 3> ❑ Domestic/Private 8 Gravel Pack ❑Tracy Type of Casing pyG. Specifications 1 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _sem PT_ -_ Type of Grout ❑ Irrigation 4,-L-3Approx, Depth ❑ Eastern -Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter ; Seating Material stop 50.1 McwtTu&EaCZ LiNc L Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Unstallation 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 l 'v No. Compartments PKG, TREATMENT PLT. ❑ � Method of Disposal Distance to nearest: - WeEIFoundation Property Line � i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Prop" Line SEEPAGE PITS ❑ Depth Size Number ' SUMPS ❑ Distance to nearest: Well Foundation Property Line . DISPOSAL PONDS ❑ 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 pen-nit is issued,1 shall employ persons subject to workman's compensa- tibn laws of California." . .- le applicant must ca jl for all required inspections. Complete drawing on reverse side. `` y S1i I +.✓ G �c�/► ,_-. t `�� Title: /cru ;t cif �aLc _/s-- _ Date: ! '-� ['�4 �'u' TC�if„�.�pR DEPARTMENT USE ONLY Application Accepted by7� Date ` O� 6--- Area Pit or Grout Inspection by Date Final inspection by Date " Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 CASH RECEIVED BY DATE PERMIT N0. INFO ♦ EH 13.24IREV.1/851 -3,100 S �� E-1-7 � "` 0A / 'E—� 'S EH 1475 a -tom. �� =�