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t ,x APPLICATION FOR PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT l Efl1 E. H,4IELTON AVE. ,, STOCKTONCA P AY M EN r Telephone (208) 466-E781 R E C E t V D PERMIT EXPIRES 1 YEAR'FROM•DATE ISSUED Y5 (Complete in'Triplicate) " �`� �L' --A'Y cv Application is hereby made to the San Joaquln Local Health District for a permit to construct and/or install the work hereii��a made In compliance with San Joaquin Couniy Ordinance No.543 for sewage or No. 1862 for well/pump and the R41es and ...1.t ,,�{, ,�n Local Health District. 'r'� ��F.m �. .�. Job Address °i - -_- City Lot Size E� PM Owner's Name AddressPhone Contractor C' e, • Address License No.%!!Z72 Phone-_ `--- TYPE OF WELLIPUMP:- NEW WELL F, WELL REPLACEMENT fl DESTRUCTION i-1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FID. PROP. LINE FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS � INTENDED USE TYPE OF WELL - PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom U Manteca Dia. of Well Excavation Dia. of Well Casing Domesticl Private ❑ Gravel Pack _ ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other - ❑ Dena Depth of Grout Seal Type of Grout Ll Irrigation Approx. Depth Ll Eastern ti +. Surfay`e Seal Installed by -_ Repair Work Done IQ Type of Pump HX3!i 112`94 State Work Done J Well Destruction ❑ Well Diameter Sealing Material atop 5&:l T_4A&A' Depth Filler Material f Belo_w 601 TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIRIADDITION U QESTRUCTION L (No septic system permitted if public sewer is r available within 200 feet.) r. Installation willserve: Residence's Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet' t s`'' 'E Water table depth SEPTIC TANK _ ❑ TypVMfg. _ _ Capacity .-No.--Compartments PKG. TREATMENT PLT.❑ � r Method of D rspassl ----__-.- Distancs to nearest: Well Foundation Property line A LEACHING LINE ❑ No. & Len4tfiiti'of lines Total length/size ' FILTERBED J Distance to nearest: Well -_.-_-._ Foundation _- Property Line I ;i SEEPAGE PITS ❑ Depths' # Size Number ' ,Li SUMPS C1 Distance to 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 warkman's compensation laws of California."Contractors 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." r The applicant must cal for all required inspections. Complete drawing on rse side. �] �d I 7 If9�d"d' Signed xp Z��,e��*1t-�-�_ Title: ��t- Date: FR DEPARTMENT USE ONLY r Application Accepted by Dates Area i v Pit or Grout Inspection by Date Final Inspection by t Additional Comments: U Stk 466-6781 J Lodi 369,3621 I L Manteca 823-7104 U Tracy 835-6385 Applicant- Return all copies to: Environmental Health Per-mit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk.,CA 95201 i# t - l _ AMOUNT OUNT DQUE AMO{U�N'TREMFED CASH K* RECEIVED BY DATE ..- PERMIT'NO- INFO + rrev. es EH"A JPU ;fA ;