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. . . . APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �� [V�D 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ApR 2 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ZAP H�p,L'�H (Complete in Triplicate) �ty�IR� M�I5�RV1[ES 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. 6 Job Address t�e rO-7 ils. L CJ Y2�I , �(ZLr� City Lot Size PM Owner's Name �J/J[LQ_. 111. 1• Address o2467c9 'S. LOf'Yu[ Contractor Address o2fs isrense No. Sr,� Phone l fJ TYPE OF WELL/PUMP: U NEW WELL ❑ WELL REPLACEMENT 3K DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /©a SEWER LINES DISPOSAL FLO. IC50' PROP. LINE FOUNDATION--"°'—'--"'A'GRIC 11L~TtJRE`WEU'L"""OTHER`WEL-I~ rL PITSYSUMPS— -'4 - F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ri ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /oZ " ., Dia. of Well Casing Domestic/Private Gravel Pack Trac Type of Casing VC, { '� Y Yp 9 Specifications ❑ Public ❑ Other C-} Delta Depth of Grout Seal 1Eb ' ,Type of out t ` I I Irrigation --Approx. Depth I ! Eastern Surface Seal Installed by 4 Repair Work Done ❑ Type of Pump H.P. State Work Done ] 11 Well Destruction ❑ Well Diameter Sealing Material (top 50') / Depth Filler Material (Below 50') U TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l 1 DESTRUCTION l I (No septic system permitted if public sewer is �I available within 200 feet.) �! Installation will serve: Residence_...; Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity- 1 ' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line II LEACHING LINE ❑ No. & Length of lines f 9 Total length/size a FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS i I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line -y DISPOSAL-POND5:� ❑ sr 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 Di$trict. r 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 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 Calif rnia." The appli nt t cafl for all required it ctions. Comply drawing on r v se (de. " Signed X le: y �g Date: F DEPARTMENT USE ONLY Application Accepted by —Z— Date �~ Area V Pit or Grout Inspection by Date Final Inspection by ate Qv Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 C] nista 3-71 ❑ Tracy 835.6385 ; __ Applicant - Return all copies to: Environmental Health Permit/Services 1601 azelton Ave., P.O. Box Stk, CA 95201 .5�11—/Yo'el r w y `1 fwd . f-�[ wd+-fd !r/fie INFO AMOUNTCUE AMOFEE UNT REMITTED K R EIVEp BY DATE PERMIT N0. +.EH 14-24 IflEV.i/n 51 Li EH 14-28 M