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/ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA — - Telephone 466 — PERMIT EXPIRES 1 YEARAR FROMM D DATE ISSUED (Complete in Triplicate) OA Application is helehy made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desc;, :�his application is made in Innythonce With San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulaof the San Joaquin Local Health District( Job Address (i1�iLiGfC4City Lot Size PM 7� Owner s Name ..�. 'J t Address .� C �' 7/1 1 ren t �J IV' Phone!dod'_i -_G/,y Lc Conlradnricen Address3o °Ls No.� �r4� 7 Phone//lS / t - TYPE OF WELL/PUMP: NEW WELL Ci WELL REPLACEMENT U DESTRUCTION U PUMP INSTALLATION L1 SYSTEM REPAIR U OTHER;I�L rt v.,.,E. DISTANCE TO NEAREST: SEPTIC TANK A-114--- SEWER LINES DISPOSAL FLD./ ._ PROP. LINE ', _ FOUNDATION ] _ AGRICULTURE WELL le- OTHER WELL 3<;-' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS H Industrial U Open Bottom U Manteca Dia. of Well Excavation Dia. of Well Casing L _ 1 1 Domestic/Private X Gravel Pack l" Tracy Type of Casing LSpecifications I Public I I 011ie, /I I Delta Depth of Grout Seal L1 Type of Grout G(C nir 11 I It q tabun /J' Approx. Depth I I Eastern Surfac Seal Installed by /',,V— fart Ji C. Repair Work Done I I Type of Pump 4 Cf H.P. �7 State Work Done _�' Well Destruction I 1 Well Diameter _ 2-•• Sealing Material (top 50') ry C>�• Srn�; Depth _-_�`/_ -__�_ Filler Material (Below 50'1 r t rr,�i�Cj✓r�t- C�_ �r TYPE OF SEPTIC WORK: NEW INSTALLATION I h REPAIR/ADDITION i DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence __. Commercial Number of living units: ___ Number of bedrooms Character of soil to a depth of 3 feet -— --------Water table depth___ SEPTIC TANK I I Type/Mfg -_ _. - _- —,,. Capacity______ No. Compartments PKG, TREATMENT PLT, I I Method of Disposal Distance to nearest Well Foundation Property Line LEACHING LINE I No. & Length of lines Total length/size__________ FILTER BED Distance w nearest: Well ___ Foundation Property Line SEEPAGE PIT'S I ! Uepth Sun Number SUMPS I I Distance to nearesC Well _- -__ Foundation _ Property Line_ DISPOSAL PONDS I I I hereby certify thal 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 Joequin Local Health District. Nunre owner of I¢onsed agent's Sit ptaturc corollas the following: "I certify that in the performance of the work for which this permit is issued. I shall not employ any person"ch ch manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature cenibos the InllowKi l certify tl�I ii..n laws of Calilnnu71 the pedo+manco of the work for which this permit is issued, I shall employ persons subject to workman's compensa- ' The applicantn rst all f all irxr f inspections. Complete drawing on revoBe-Side. Signed X.— _.- _- Title: f'YEiSt� l'r Z Date: �{"- C P t d `� s FOR DEPARTMENT USE ONLY [J I r Application Accepted by Q (tca `7i^ t'wt C G,C f, � f(MCd _—I _ Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 1 ! Stk 460-6781 CJ Lodi 3693621 ❑ Manteca 8237104 ;_1 Tracy 835-6385 11 Applicant 1tReturnall copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CAJ 95201 t1> i(1nSRn c"t�oy �J f ' 1 I/x20'V- FEE ✓«.Q�\ wlo q ✓uucl L -.5-c_ D.,cl TIL r^xl,LCw;Cd CON`V4cCa 1r r'j�Y lw.0 c� . FEE INFO AMOUNT DUE AMOUNT REMITTED K N RECEIVED BY DATE PERMITNO. Ell 13-zx(REV x EH lx x ✓ f _ �� J