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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH �DISTR�ICT �` ,�NIE��E) 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781� J U i 2 4 !.._ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN COUNTY i PUBLIC HEALTH SL'RMES (Complete in Triplicate) ENVIRUNNIENTAL HEAL;H DM,Q;rC' 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. z3G 7.S Sv, 1 r r f Gl1 2Cc,` �.4G PM Job Address r_ i City Lot Size Owner's Name l�!'�T SP ___— Address I 2.&a d -/ Phone Contractor m !hX Address?6ZS �t I License Na�-7--ZC.a Phone 46S-87/z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION$ WEu.5 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ # OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES /U>/� :IDtSPOEAL FLO. PROP. LINE �d FOUNDATION ,S� r AGRICULTURE WELL .tf/AOTHER„WELL 9,5” PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CI Industrial ❑ Open Bottom 1% Manteca Dia. of Well Excavation I " Dia. of Well Casing h ❑ Domestic/Private W Gravel Pack ❑ Tracy Type of Casing Specifications 4 F'1 Public Fl Other Cl Delta Depth of Grout Sea h Svc Type of Grout C r&-e— I I Irrigation —Approx. Depth l I Eastern Surface Seal Installed by drum _ Repair Work Done ❑ Type of Pump H.P. it State'Work Done— Well Destruction Well Diameter Sealing Material (top 501 zi Depth`>' 1d,Z3, 2S_I _ Filler Material (Below 501 I. TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 F! :,A 18!ADDITION I I DESTRUCTION i 1'(No septic system permitted if public sewer is ' available within 200 feet.) • f Installation will serve: Residence_ Commercidl Other i 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 i 1 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property tine I� LEACHING LINE ❑ No. & Length of lines ([Total length/size FILTER BED ❑ Distance to nearest: Well Foundation i Property Line SEEPAGE PITS I l Depth Size Number SUMPS P Distance to nearest: Well Foundation ! Property Line DISPOSAL PONDS Cl 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 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." -D !i The applicant ust c I for II re r�inpections. Complete drawing on reverse side. Signed X Title: 1\ � / kIS lea fi Date: W FOR DEPARTMENT USE ONLIIY V Application Accepted by ; Date Area 7 f � i� Z Pit or Grout Inspection by ?� nom( n�: Z Final Inspection by t Additional Comments: lr4.l iJ 4=K,QZ:zr ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mant ca 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 1 FEE AMOUNT DUE AMOUNT REMITTED CKRECEIVED INFO CASH BY DATE PERMIT NO. l ♦.EH 13-24IREV.IIK5) 610 Z,-r�°^ 3i/� 1 ' P, EH 14-28 c v