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' f i APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephohe (209) 466-6781 v y iPERMIT EXPIRES 1"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 Rules and Regulations of the San Joaquin Local Health District. / f // Job Address r`1 I j s1_ City 40 - Lot Size/D PM Owner's Nameba V C �[A �'(� I ;Address I �� 1-6!5 j,� �. �S?� Phone � fi j.- Contra to Contractor AddressT '" L1cerfg Ni3-Z'q� " `Phony -7 - -TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION r< SYSTEM REPAIR ❑ }. OTHER ❑ 7 DISTANCE TO NEAREST: SEPTIC TANK [ SEWER LINES DISPOSAL FLD. PROP. LINE 731C� t FOUNDATION AGRICULTURE WELL' ' OTHER"NVELL,- PITS/SUMPS _ C " �r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI~ S-- r+ :❑'Industrial yI.EOpen Bottom ❑ Manteca -�*�Dia. of Well Excavation - Dia. of Well Casing f ❑ Domestic/Private _❑ Gravel Pack�• ❑ Tracy Type of Casing 57e-e—1 Specifications � - ❑ Publict J ❑,Other "" ❑ Delta Depth of Grout Seal �" Type# Grout '�e�e t >Qrrigation y0 .-Approx• De th { I Eastern Surface Seal Installed by ' ,t i t tie air.Work Done ❑ T .7 p a Type of Pumpy � W.P. '� State Work Done_ 1 Well Destruction• 1--❑'`Well Diameter Sealing Material (top 501 ti Depth Filler Material (Below 501 TYPE OF SEPTIC WORK':, NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I i (No septic system permitted if public sewer is * available within 200 feet.) r� Installation will serve_~Residence_ Commercial_ Other Number of living units: Number of bedrooms ; l r t = Character of soil to a depth of-3 feet: Water table depth f SEPTIC TANK ❑ Type/Mfg t Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ Method of Disposal! ,• ' Distance to nearest: Well Foundation f Property.Line ' f �^r LEACHING LINE ❑ No. & Length of lines Notal length/size t FILTER BED " "°` ❑. -Distance-to nearest: Well Foundation— Property Line * r. .. ice` ti `Rf SEEPAGE PITS .1 1 Depth Size_ Number " t SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and f rules and regulations of the San Joaquin Local Health Di1trict. r z 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." V The applicant st call for all required inspections. Complete drawing on reverse Sid tC i # Signed _(_.�,/��'��, Title: - Date: 0 t FOR DEPARTMENT USE ONLY Application Accepted by V-19 �+ Date 3 Area dN Pit orro Inspection by Data V` _ =rt %Final I spec[on byff Date /$c Additional Comments: I-) Stk 466-678.1—----0'Lodi 369-36211 ❑ Manteca 623-7104 ❑ Tracy 635-6385 11 Applican R turn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk-, CA 95201 i 3 FEE x INFO AMOUNT DUE t AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. GASH + 1pEV.rinslVYY� EH 14-26