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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT q� 1601 E. HAZELTON AVE., STOCKTON, CA PAYMINT Telephone (209) 466-6781 R 1ven PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JAN i (Complete in Triplicate) SAN � � T Jo Applicanon is hereby made to the San aquin Local Health District for a permit to construct and/or install ITid � s � {�ication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump ay(AfaOl��egur "�Ah Joaquin Local Health District. Job Address le:�,0 641 I C City� Lit Size__1>&h' _ __ PM Owner's Name -44412r4 cSCc.sDQE,QS�..�iyc. Address 6R O.0-'k66,C* Phone 7-1"?_ I ��t a 9atSGS ColZiractar�/y led}- A tr a 5.7.v��.�a Address k3 W. /y1i5l�ch�-,.1�. 57X.tJ License Na. S/via G d Phone�v -•17 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 9 o2-50;4• &0,t-401" DISTANCE TO NEAREST: SEPTIC TAxNK >o;Pel 0 SEWER LINES > o2cuU f DISPOSAL FLD. i_4 y PROP. LINE >��z FOUNDAThON Is" AGRICULTURE WELL OTHER WELL! PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C.1 Industrial LI Open Bottom ❑ MantecaDia- of Well Excavation g /�7AJG Dia. of Well Casing I C] Domestic I Private L-I Grave) Pack D<Tracy Type of Casing_ l�,�A Specifications I1 public. f D<Other 604e ii, n Delta Depth of Grout Seal ��bz�sOie<. Type of Grout ��i.«�.11M/ ee.oS6 z%,�n,e.a iiI�IIc Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by, SPEC-77¢ce.H. ,r! C. Repair Work Done �[3 Type of Pump A0A H.P. ti/f3 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') -AL1,4 � VVV 'i Depth tAs -PlR4X Filler Material (Befow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) I Installation will s e: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 1-1 Type/Mfg Capacity No. Compartments E PKG. TREATMENT PLT. ❑ I Method of Disposal 1 4 Distance to nearest: Well Foundation Property Line LEACHING LINE C-] No. & Length of lines Total length/size FILTER BED 1(//,4 ❑ Distance}to nearest: Well Foundation Property Line SEEPAGE PITS' I I Depth Size Number SUMPS �(//� 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 lb 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 California." f The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: _1PkaMv— /�-1/}�i fir(: Date: I A 7Z�_U l Jt d y f. s✓� s 7Z..-, �-mac FOR DEPARTMENT USE ONLY Application Accepted by Date 1—,? 9 - YO Area Je/3 ar Pit or Grout Inspection by 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.D. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED By DATE PERMIT'NO. INFO A5H l l . F.H 13-24(REV,r�nf,l } * 1 EH 14 26