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� a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED ' (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of 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. Job Address �� 1J, k/ L-S OA]l W A t/ City S'rJ� Lot Size /0 X 2-do / PM Owner's Name_ Address Phone - a Contractor `4V'9D 4 + G[ vv- Z_Address 7 Al .d's7t�4-6 -r License No. Y!`2-76 Phone � —3 P TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION-❑ SYSTEM REPAIR' ❑ •OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION? AGRICULTURE WELL;"* OTHER WELL ' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (1 Public Ll Other f1 Delta Depth of GroutSealType of Grout _ I I Irrigation Approx. Depth 11 Eastern Surlace Seal Installed by _ . is Repair Work Done 0 Type of Pump H.P1. State Work Done I Well Destruction ❑ Weil Diameter Sealing Material (top 50') Depth,-, Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION ' DESTRUCTION i I (No septic system permitted if public sewer is / available within 200 feet.) Installation will serve: Residence Commercial____ Other Number of living units:: Number of bedrooms �' C Character of soil to a depth of 3 feet: C t—i `! �" - Water table depth mil SEPTIC TANK r ❑ Type/Mfg _o69 I s?-7A-1G Capacity No. Compartments ; `Y -PKG. TREATMENT PLT. ❑ Method of Disposal Y Distance to•nearest: Well Foundation Property Line ,LEACHING LINE NoF& Length of lines �� Total length/size .SO�' Z FILTER BED"', - .r- ❑ Distance to nearest: Well S-0 Foundation :!�O Property Line ' � k SEEPAGE'PITS 1.1/' Depth �r "'Size f�Number SUMPS /0 Distance to nearest: well 160 Foundation Property Line 7Q � DISPOSAL PONDS 0 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 4 rules and regulations of the San Joaquin Local Health District. f 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 Shalt 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 Califor6ia," The applicant must call for'all•rouired ins ctions. Complete drawing on reverse side. 7 Signed X_ � Title: M � Z- Date: / f g, ' 6 FOR DEPARTMENT USE ONLY Application Accepted bDate `�` 1 Area 1 Pit or Grout Inspection Date Final Inspection by Date Additional Comments: 0 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 FEE 01 INFO "71D NT DUE AMOUNT REMITTED CK H RECEIVED BY f DATE PERMIT'NO. + EH f3-24{qEV.i/H51 �+ f!!! O' vO 5CIz t{l/� l x•,•l�Q�� EH 14-2e F"