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APPLICATION FOR PERMIT J6 SAN JOAQUIN LOCAL HEALTH DISTRICT _ 1601 E. HAZE T ON SAVE., STOCKTON, CA 7 1984 IJ F Telephone'.: (209) 466-6781AN JOAQUIN LO C,gL' PERMIVE_XPIRES 1 YEAR FROM DATE ISSUED � Fql �� ISTRrr--�- F (Complete in Triplicate)` Application is hereby made to the San Joaquin. Local Realth 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. 649.for sewage or No. 1862 for well pump and the Rules and Regulations of the San Joaquin Local Health District. r�/1 Job Address r2,30 6 b 741JIJf - City Lot Size../,? aZ4,gA J PM Owner's Name�ILCA, GfGf ZUAde;,6y,4�Address 7 PTione % - 7 I , Contractor's Name } _-_ - DISTAN License No. Phone SELL/PUMP: NEW WELL X' r WELL REPLACEMEN j DESTRUCTION❑ PUMP INSTALLATIONS O SYSTEM REPAI OTHER ❑ TO -'NEAREST: SEPTIC TANK - - —SEWER LINES - DISPOSAL- FL -D:. 7 - PROP.. -LINE- - - ,F _•FOUNDATIONS-- AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ❑ Industrial XDomestic/Private ❑=PublicA + ❑ Ir'riga_�tion ` Repair Work. Done ❑ Well Destruction ❑ TYPE OF WELL 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ OpenBottam�r; Manteca Dia. of Well Excavation 'Gravel Pack ❑ Tracy . Type -of Casing soya ❑ Other .' ❑ -Delta r , Depth of Grout Seal 160' -Z-Approx. Depth ❑ Eastern Surface Seal Installed by G Type of Pump H. P. State Work Done _ Well Diameter Sealing Material (top 501 ,/Depth Filler Material (Below 50') ! ��f f Dia. of Well Casing Specifications Type of Gr ut TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is f available within 200 feet. ) Installation will serve: Residence — Commercial _ Other Number of living units:-- Number of bedrooms d Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg4 f Capacity No.'Compartments PKG. TREATMENT PLT. ❑Method of Disposal Distance to nearest: Well Foundation Property Line LA I_ LEACHINGLINE ❑ No. 6 Length of lines.' Total length/size 1 k FILTER BED ❑ Distance to nearest: Well Foundation Property Line i i SEEPAGE PITS ❑ Depth Size Number aM.. --SUMPS - - T- �-;O�Distance to nearest: Wei! --= �-�FaUnclation �" �""'�Propeitp-L'ine.,_"-""� DISPOSAL PONDS ❑ f 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. k 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." Contractors hiring or sub -contracting signature certifies the following: "I certify that in the performance of the work for which iris permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." y The applic nt fnust call for•all required ' etions. Com ete drawing on a side,, ,y/ f Signed u itle: Date• .DEPARTMENT USE NLY - -w t !T G 6 Application Accepted by t - Date • " Area �' Pit or Grout Inspection b -ii - v q Date 1-1 �-� •, inal Inspection by r+-- �� jr� �c Dater "��d : ac 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 t o - . FEE (��c� INFO AMOUNT DUE j AMOUNT REMITTED CA9H RECEIVED BY DATE PERMIT `NO. EM24 (REV, tures,EH 114-26