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Pp►Y�`VEp • APPLICATION FOR PERMIT REGI SAN JOAQUIN LOCAL HEALTH DISTRICT '1601 E. HAZEL T ON AVE., STOCKTON, CA JU f Telephone (209) 466-6781 TAL HE PERMIT EXPIRES 1,YEAR FROM DATE ISSUED tiN�l )OMEN ATISERVICES (Complete in Triplicate) fps— 't +?J 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. + , `t Job Address ._ tt1 X4.O N Qy U1 I -0 r City Lot Size r'Q 4-C PM lster Owner's Name j © L e Address 192 Phone -1147 Contractor 5pea Address af.70c,J S License No.-!5j Phone — �S7 71a TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION LlSYSTEM REPAIR ❑ OTHER 11/&i't i-WeI1 " DISTANCE TO NEAREST: SEPTIC TANK ? _ SEWER LINES, 55 ' DISPOSAL FLD. PROP. LINE A [ ` ' FOUNDATION AGRICULTURE WELL OTHER WELL r�3t� PITS/SUMPS �O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing a� I ' ❑ Domestic/Private Gravel Pacrk ElTracy Type of Casing Specifications 1 F'1 Public f_1 Other .. C1 Delta Depth of Grout Seal A-, 13--/61 Type of Grout &_6L2 aiE ' I I Irrigation 26.-Approx..Depth ro" Eastern Surface Seal Installed by SpeL6r m F__XP� Repair Work Done ❑ Type of Pump Nr,ne H.P. State Work Done_ Well Destruction ❑ Well Diameter all Sealing Material Itop 50') A&— A)ca' cern eA;& 1' X'T�$'✓�r .. .Depth 3 �_____„-_,,,-_,_ Filler Material (Below 50') r I If TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION ! I (No septic system permitted if public sewer is available wrllhin 200 feeLl Installation will serve: Residence Commercial _ Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg } Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal T Distance to nearest: Well Foundation Property Line . LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED” L1Distance toynearest: Well Foundation Property Line SEEPAGE PITS I I Depth I t Size Number ' ❑ Distance totnearest, Well Foundation Property Line DISPOSAL_ PONDS O 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 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature t 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." The applicant must call for all required inspections. Complete drawing on reverse side./� Signed X n Title: 5-La" l : `-}t Date: — 7/9 195?VUk OR DE RTI€N USE ONLY rf Application Accepted by � ` Date -I- iq ttg Area yfi Pit or Grout Inspection b / _ � E Y Date �• Final Inspection by � Dat"' Additional Comments: �" �► C",it "to'' —r (0.4 Z— aldve.,.c— � ❑ 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 I' FEE (T INFO AMOUNT DUE AMOUNT REMITTED K' RECEIVED BY DATE PERMIT'NO. EH 13-24+.EH 11281flEV-