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i APPLICATION FOR PERMIT SAN JOAO.UIN'LOCAL"'HEALTH DISTRICT r^ _t 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` f (Complete in Triplicate) IP l t �" '1w. :. .�. +.. . - _. , 1.�. - - y y,. .< ,i sA. ' . y- 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. /�J , : g:hr tCr? ' Lot"Size (et^-�[�WJ 'PM Job Addre CiNI of 1C' t a �..,.iOA ' a Owner -791 's Name = Address- Ll,5700 . -- -"'Ih�_-on77e�� r P O_�&X 4Q aG O a[ Phane —S Contra ct Address License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ „t OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE �1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS y %x 4 NTENDED_USE-v TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 i ❑.industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ 'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Sea! Type of Grout I ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by I 11 Repair Work Hone E] Type of Pump H.P. State Work Done l 9 Well Destruction E3 Well,Diameter Sealing Material (top 501 S I Depth Material (Below 501 TYPE OF SEPTIC WORK`: "i.NEW INSTALLATION ❑ EPAIR/ DITION DESTRUCTION 11 (No septic system permitted if public sewer is C J available.within 200 feet.) III installation.will-serve:_..Residence�_Cohnmercial Other s " Na umber of•liVing'units':t r' Number'o rooms ` l Chara t r of soil to a depth of 3 feet: r �' Water table depth �✓ SEPTIC TANK❑ ' Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ li i 'Method of Disposal t Distance to nearest: I Weil 4 Foundation )Property Line . LEACHING LINE 51—No. & Length ofk fines _ _ P Total length17sife w iFILTER BED ❑.. Distance 10nea!st: Well .SD Foundation 066 :r.._dP�operty Line S f I SEEPAGE PITS- --- Depth — Size Number # 121 SUMPS ❑ Distance to nearest: Well/fin Foundation 10... Property Line DISPOSAL PONDS ❑ ` hereby certify that I have prepared this application andthat the work will be done in accordance with SaK J6i iquin county ordinances, state laws, and 1 rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies th0ollowing: "I certify that in the performance of the wo k.for which this permit is issued, I shall not employ any person in such manner as to become subject fo 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 pe1_s6ns subject to-workman's compensa- tion laws of California." The applican must call fo II r uired inspectionsComplete drawing on reverse id_e_. .; Signed �` -t Title: ��sT Date: v "f FOR EPARTMENT USE ONLY �f E Application Accepted by �� Date ' � Area v opit, r Grout Inspection'by °➢ Date Jr J Final Inspection by Date k Additional Comments: HI ❑ Stk 466-6761 ❑ 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 i FEECK 1 i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY /BATE PERMYT"NO. x _ + EH 13-241REV.1/65) i - - �(�S�g� j •{��r '. EH 14-26 C t . - - i