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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA f Telephone (209) 466-6781 PERMIT EXPIRES 7'YEAR FROM DATE '" Z (Complete in Triplicate) ` C4 `3- Application is.hereby made to the San Joaquin Local Health District for a permit to construct eses- made in compliance with San,Jo-aquin County Ordinance No.54B for sewage or Nv. 1$62 for wellp/ump and the Aues and rk rRegulationsdrbed." his applicai, n is- Local Health District. 4 -_ t.w ! of the San Joaquin ��`f;=�d'' �G Job Address 000 /7+� I ! p O )� PM City F+ s.. Lot Size '�. o p�o.�fcrtq� !r ;Q Owner's Name CIOD • L Ad r s S fR 40 '" �}��one a 3&9-A' A Contractor Gam: _ � � 1 { ,rte �:rPn+p'f �11s3 G Address i Ela I C rt ST S rr License No.��3 s�� Phone l S —oll/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJDESTRUCTION LJ w7 r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER •f,$ M i t� rl r, DISTANCE TO NEAREST: SEPTIC TANK 1 SEWER LINES DISPOSAL FLD. PRO E r fS FOUNDATION .AGRICULTURE WELL OTHER WELL ..PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - M0111 r'"#I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ^� : ❑ Domestic/Private Gravel Pack ❑ Trac Dia. of Well Casing Y Type of Casing +� V� Specifications III Public ❑ Othe ❑ Delta Depth of Grout Seal "+- 'iL f !FI Irrigati n ,'t �D� Type 4f Grout pprox. Depth € I Eastern Surface Seal Installed by_.. C,0rA , ht/� epart or bone ❑ Type of Pump H.P. State Work Done_ l Weil Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material [Below 50') TYPE OF SEPTIC W NEW INSTALLATION I I REPAIR/ADDITION I.I DESTRUCTION I I 1 eptic system permitted if public sewer is r j Installation will serve: 'ResideCommercial_ Other vailable within 200 feet.) Number of living units: Num f bedrooms Character of soil to a depth of 3 feet: SEPTIC TANKWater table depth ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ artmt _ Method of Disposal Distance to nearest: Foundation Property Line LEACHING LINE ❑ No. & Lengt fines Total length/size FILTER BED ❑ Distan o nearest: Well Foundation Property Line SEEPAGE PITSk I Depth Size Number on SUMPS ❑ Distance to nearest: Well Foundati DISPOSA NDS ❑ Prope ine i 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 I` 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 must call for all required ins ctions. Complete drawing on reverse side. _. ./+�i�wZtc c I NC... s+n Signed X . 1a r '��• // r� C.p. - kit'.Ir `.� �Q r Date: . FOR DEPARTMENT USE ONLY j Application Accepted byZ 1� I Date_�._�- _f. Area Pit or Grout Inspection by Dat l�' Final lnspectio v D LS n Additional Comments: '-�e. ►r.n o._ } Ac t,t,�+v 1oc..4 ..s ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 I Applicant Return ❑ Tracy 835-6385ttall copies to: Environmental Health Permit/Services 1601 E.'Hazelton Ave., P.O. Box 2003, Stk., CA 95201 ' FEE "?G� �"`�q vw�G-eT •+��•r� t+r, _ INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY f C H DATE PERMIT NO. + EH 14.28 EH 13-24(REV.tin 51 S. I Y7 3�f30