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APPLICATION FOR PERMIT ' SAN JOAQUIN'LOCAL"_HEALTH DISTRICT �+ 1601 E. HAZE T ON AVE., STOCKTON, CA 1 Telephone (209) 466-6781 '1PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1' t (Complete in Triplicate)' 4 . Application is hereby made to the ,an Joaquin Local Health District for a permit to construct and/or install the work herein described..OThis application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local"Health District. - l . .......-.. souh ny''99- 2739 Joh Addresst-.: _ a. STOCKTOY 3/4a6- . , - Lot Size1. PM Owner's NameSTOGUON. MOTORCYCLES_.�`d�d'r��l PO BOX 1943 } . ° �:�r Phone 8-0 2 ContractorKE..l�;TH GROSS Addres 0' BOX 1' S-�' aODBRTDC.rT.' r - �j�773S,3 x TYPE OF WELL/PUMP: NEW WELL icense No. Phone 3 -4 2 r �+ ", WELL F�EPL4CEMENT ❑ DESTRUCTION ❑ 1 PUMP WSTAL�LATION_p 3c7,'- SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC 6NK F "" "`----^---� — OTHER_❑ _ s SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION:I AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMP$ ❑ Industrial ❑ O/pan Bottom: x❑ Manteca d *iE*Domestic/Private *a6f,G 'Pack I Dia• of Well Excavation Dia. of Well sing 9 1�C I ravel I❑ Tracy ❑ Public O`Qther i I Type of Casing a Specifications ❑ Delta Depth of Grout Seal I C:�D& ❑ Irrigation 200� A p Type of Grout pprox. Depth ❑ Eastern Sur#ace Seal Installed by Repair Work Done. ❑ Type of Pump ��. H.P. � Well Destruction ❑ WeH Diameter { j State Work Done Sealing Material [top 50'1 Depth Filter Material (Below 501 / TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted/if public sewer is Installation will serve: Res di ertce i 4 available within 200 feet.)/ Commercial_ Other Number of living units: Number of bedrooms f r Character of soil to a depth of 3 feet: SEPTIC TANK { Water table depth ❑ Type/imfg I Ca PKG. TREATMENT PLT. E3r I pacity No. Compartments,,-w I € i Method of Disposai�`' Distancle to nearest:: Well Foundation i I Property Line LEACHING LINE LlNo. & Length of lines FILTER BED f Total length/site ❑ Distance to nearest p Wel! Foundation _ " Property Line/ � may. .. SEEPAGE PITS ❑ Depth Size SUMPSNumber `` I ❑ Distance to nearest:. Well Foundation DISPOSAL PONDS ❑ f j Property,Line•. hereby certify that I have prepared this application and that the work will be done in accordance with Sari Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. f Home owner or licensed agent's signature certifiesithe following: em Io an "'I certify that'in the performance of the work for which this permit is issued, I shall not employ y person in such manner asJto become subject to workman's compensation laws of Callfornia.,'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- tion laws of California." ! 1 r The applicant must call for ll req 'r d inspections! Complete drawing on reverse side. r I Sighed Title: } 1 q 1 Date: _ i- 71F(&R-DEPARTMENT USE ONLY' k t'1 'Application Accepted'by g ate r ' t D ��p Area Pit or Grout Inspection by Date 3 " ?Final+Inspection by Date (O T O Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑/Tracy/835-6385 Applicant- Return'al!copies to: Envir"nmental'Health Permit/Services 1601 E./Hazelt n Ave., P.O.Box.2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K INFO RECEIVED By: DATE PERMIT NO. t EH 13-24(REV.1/851 + i EH 1426 0 s