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iAPPLICATION FOR PERMIT SAlpAgtaffOCAL HEALTH DISTRICT 1 IDN AVE., STOCKTON, CA lir l�'lY' e eD�gqhgqo((n��e (209) 466-6781 PERM�I'�1��(RIAE3 OYEAR FROM DATE ISSUED SAN JQAQL{ ^6 ,. Triplicate) P Bt-IC HEAL N Application is hereby made to the San Joagylt�l l% 7MQWiAtT(W @M&W construct and/or install the work herein described. This application is made in compliance with San Joaquin Co. mance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. w� Job Address " ' �'�`aC,�_Aon �y� City n Lot Size PM Owner's Name "' Der o Address /, d`,Rp'k /S71f%.�dp• 69,9W6 W6 Phon�2Q7J� Lou�r�i�� ;�4v>�/� ,Tic- Zo f/''9r>Fef ,red�n9i6)2f4 9703 Contractor Address License No.'s�9#-6 Phdne_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ` tr PUMP INSTALLATION X SYSTEM REPAIR ❑ �OjTHHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES>_Sd'0 DISPOSAL FLD./10/- PROP. LINE y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 -t Depth Filler Material (Below 50') 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.) V, 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 0 No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS 11 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 permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant t call for all re it inspections. Complete drawing on r verse side. ` Signed X ;'77 ��'`�`«" Title: �2U� Date: I 12 v F DEPARTMENT USE ONLY ': ,// Date .t• 7 �l Application Accepted by /h -- Pit or Grout Inspection by Date Inspection by Da� Additional Comments: �/f '`S��f' /,��; ��£;i ,��•.� � �I:y�!- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 RECEIVED BY DATE PERMIT'NO. INFO a EH13-24(REV.i i e 5) EH 14-26 _CS` (Ct z ��9 0 � a