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s " ' — APPLICATION FOR PERMIT as r_ SAN JOAQUIN LOCAL HEALTH DISTRICT A IV 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 � J PERMIT EXPIRES TYEAR FROM DATE ISS .: i (Complete in Triplicate) DEC Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of install the work herein described. Thid'appl_,, is made in compliance with Son,Joaquin County Ordinance No�549 for sewage or No 862 for well/pump and the Rules and`� ,tK�s of the San Joaquin . V:_�^zTt�E .a ✓ =.�� Ste—j�o'� r,� rR� y�R�rl� Local Health District. ✓^ate +� 12, _ City Lot Size /PM RvfC�s Job Address �� A�J �!Q�w �n A0,&1C,190 I 9S2Y1 ? p Owner's Name 0 I ^"�� a Address �D C.�.Q/brLPe�r 40, +� Phone _ L F•e�•l err, � yys3$ Contractor a t4 Address ► s L License No. 3� Phon4(---� � TYPE OF WELL/PUMP: NEW WELL Nr WELL REPLACEMENT ❑ DESTRUCTION ❑., , u1 �OM�►'jFO,r'f�'`� � , PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ry ll ❑ Industrial LJOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ,I Gravel Pack ❑ Tracy Type of Casing .5 CA yip PV C Specifications l'l Public f-! Other ❑ Delta Depth of Grout Seal SIM Type of Grout -_��-__- I IrrignM t � ► �QApprox. Depth I ] Eastern Surface Seal Installed by d Of a r or - Re ane Type of Pump H.P. State Work Dane Well Destruction ❑ Weil Diameter Sealing Material Itop 501 s Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INST LATION 1,1 REPAIR/ADDITION i I DESTRUCTION l I (No septic syst permitted if public sewer is available n 200 feet./ Installation will serve: Residence_ Co ercial Other Number of living units: Number of bedr ms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capac No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ndation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Foun n Property Line SEEPAGE PITS { I Depth Size umber SUMPS 0 Distanc 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 k employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature f 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 ca or all required inspections. Complete drawing on reverse ssiid'e'. r ,, � p Signed X I-�- tit `�1 1}-Yl C- O✓I _ Title: F1 J 11t fL0! /f� Date:IV- e 5 Application Accepted by MLFOIR DEPARTMENT USE ONLYl Date f Y Area Pit or Grout Inspection by Date ti(kk Final Inspection by Date 1 9/44' Additional Comments: © 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 CK# RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-24 1REV.I/K 51 EH 14-28 3