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J APPLICATION bR•PERMIT r a SAN JOAOUIN LOCAL HEALTH(DISTRICT PAYMENT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 MAY 2. 1 1119q PERMIT EXPIRES 1 YEAR FROM DATE ISSUEd AN JOAQUIN COU'NTY (Complete in Triplicate) P BLIC HEALTH SERVICES p.1(I NMQTALA' L V151 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or insta t e wo e.n n a kation 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 ^ 1 'V 6 litA 1614on City < h Lot Size PM 1 M CIO , d 9 bneOwner's Name b T ress �� '+ 1 b� Chf I t _ Contract Address License Na. 2_0 Ph TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM.REPAIR ❑ OTHER I�L #4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIQNS 2!� C Industrial ❑ Open Bottom CI Manteca Da. of Well of .� Dia. of Well Casing C Domestic/Private P-6-ravel avel Pack ❑ Tracy of Casing—N(_ _ Specifications {nVrT C Public O O)her ❑ Delta Depth of Grout Seal Type of Grout C Irr a 'o 55:�Approx. Depth astern Surface Seal Installed by �1 ❑ Type of Pump H.P. State.Work Done Well Destruction ❑ Well Diameter Sealing Material (top-50') Depth Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is S available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number-of bedrooms Character of sori to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg r Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE 01, No. & Length of lines Total length4size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS O Depth Size Number SUMPS ❑ . 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 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,1 shall employ persons subject to workman's compensa- tion laws of Carrfomia." The applicant miulot call r all wired inspections. Complete drawing onn reverse side. Signed X Title: + 1 D C Date: :5-1,UVtW 5. JfNDE-RS0^/ FOR DEPARTMENT USE ONLY Application Accepted by Date f�� A a Pit or Grout Inspection by Date 3 G Final Inspection by Date Additional Comments: 71 ❑Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83S-6385 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED As H RECEIVED BY DATE PERMIT NO. INFO ` � !`yam r ` �j { + Hi 13-24 IREV.t/951 ��... �� 60117711 '\ `1�(1p —to 1 5v _