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�� ) �_SAN APPLICATION FORPERMIT JOAQUIN LOCAL HEALTH DISTRICT 1601 E..HAZELTON AVE,, STOCKTON, CA" Telephone {209) 466-6781 5, PERMIT EXPIRES 1'YEAR FROM DATE ISSUIsp >„� t . .,.. . N {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 end the Rules and Regulations of the San Joaquin Local Health District. „ r YF } P '¢« Job Address CFty ox S1zs { _�&�Owner'sName Address u�G- `�- Phalle Contractor's Name �' ` C, License No. 0— TYPE TYPE OF WELL/PUMP:' NEW WELL WELL REPLACEMENT ❑ DESTIIUCTION PUMP.INSTALLATION; SYSTEM REPAIR 0 � � ATIi�R DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL„P4D; P�{f�P FOUNDATION I °' AGRICULTURE WELL OTHER WELL PITSj(S�Jh?IPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT!6 r ❑ Industrial %J Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wale Casing- 'mf Domestic/Private ❑ Gravel Pack El Tracy Type of Casing y Sgspifig8t�ns ❑ Public [0� Other C5pelta Depth of Grout Seal Type bf C�p�if ” r' El Irrigation ;gyp_0�pprox. Depth ��❑ Eastern Surface Seal Installed by t Repair Work Done Type of Pump H.P. State V►Jgrk Done; `Jl Well Destruction ❑ Well Diameter Sealing Material {top 50'i Depth Filler Material {Below 501 �J E OF SEPTIC WORK: NEW,INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is i'J avatlabla within 206f' t l V Installation wi e: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 Water table depth } SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal, c Distance to nearest: Well Foundation Property Line _- �- LEACHING LINE Cl No. & Length of lines otal length/size FILTER BED © Distance to nearest: Well Foundation erty Line._ f SEEPAGE PITS 11Depth " `SizeNumber ^ SUMPS ❑ Distance to nerest uWell ^Foundation Property.Line DISPOSAL PONDS ❑___ I hereby certify that I have prepared this application-and-that-the work will be done in accordance with Sa{1 Jba;uin County ordinances, state laws, and f 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 perr`ruris issued, I shall not employ any person,in such manner as to become subject to workman's compensation laws of California."Coninictoes 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." a The appli t call-fo`rall r ed in ctions. Complete drawing on"reverse'side. �, j. �* r� s Signed Title: C !L�_ Date _ FOF� P RTNT pp lilt cation Uepted l� Date Pit or Grout Inspection by Date final Inspection by Date his,^ ,e a Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mante 823-7104 El Tracy 8361Ma` ` ' Applicant- Return all copies to:,Environmental_Health Permit/Services 1601 E:Hazelton Ave., P O. $px 2009;Stk CA�gg2q}t.,r,t FEE AMOUNT DUE AMOUNT REMITTED' CASH RECEIVED BY DATE •PERNIIT`NO. INFO +EH 13-241REV.10/83) -- EH 14-26