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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I JV& #- ZO 336 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. AP/V-1, wry^ -# Z-1-3 070 'yO . sb OQGIf SUPp�y WI /�51y� Job Address Mee_ 6AgJJrZJ"k7 _Y"ff1 ?�G[/L� City l Lot Size PM Owner's Name r iAL rens E. Phone $^ r • "Y r Contracto4ftrj?_k dress?�Zrs E, R'rffLTLf �TKA(icense [Vo.51226g Phone_ y TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 13 PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES DISPOSAL FLD. P QR,-IsIAI FOUNDATIONt AGRICULTURE WELL OTHER WELL Tl� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IN Sr&V€lLa"1~C. rS El Industrial ❑ Open Bottom O Manteca- Dia. of Well Excavation g ZVI" ❑ Domestic/Private ❑ Gravel Pack 1 ❑ Tracy Type of Casing _Spee`Aeataaws FI Public ❑ Other I Cl Delta Depth of Grout Seal lye-.•a I I Irrigation —, -Approx. Depth t I Eastern Surface Seal Installed by C11�0erZr GC�►tisr/ Repair Work Done ❑ Type of Pump H.P. State Work Done_ �Sf.r1?9grVISt r Well Destruction ❑ Well Diameter a Sealing Material (top 50') ` t Depth Filler Material (Below 50') F I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION I I (No septic system permitted if.public sewer is I available within 200 feet.) 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/MfgCapacity No. Compartments q I PKG. TREATMENT PLT. ❑ Method of Disposal 6� Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size 3 FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 ` i SEEPAGE PITS I 1 Depth Size _ Number 5 t SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ S 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. 4" Home owner or ficensed 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- ~7 tion laws of California." The applicant m t call for all re uired inspections. Complete drawing on reverse side. Signed X Title: _J15AY6 . eS/ LCL IST Date: F R DEPARTMENT USE ONLY Application Accepted by Date Area S Pit or Grout Inspection by Date Final Inspection by Date Twp Additional Comments: t ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 ❑ Tracy 836-&385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 � 1 FEE INFO AMOUNT DUE 4 AMOUNT REMITTED CK RECEIVED BY PATE PERMIT NO. +.EM 13-24(REV.1/051 � S j �M417 EH 14-28 ti �..•adu 4 .�