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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ( ��J 1601 E. HAZELTON AVE., STOCKTON, CA I�If!i`�I +5 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED !UL 22 1985 (Complete in Triplicate) ENViRUiJEJAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worVE lifgs_t)i_bWIVLRgpplication 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 _iS 2 /(/C(Cf2� City /7 Lot Size ' PM r. Owners Name , Address ��a �OQL-F'YL 1 /A one - Contractor's Name <J License No. ��O�� Phone U TYPE OF WELL/PUMP: V NEW WELLX1 WELL REPLACEMENT ❑ DESTRUCTION ❑ v PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /OaD ' SEWER LINES DISPOSAL FLD.__ PROP. LINE _zoo I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION y. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing f omestic/Private Gravel Pack ❑ Trac Type of Casing 10kr_ }""' � Y yp g Specifications Cl Public ❑ Other ❑ Delta Depth of Grout Seal 5V Type oft --Approx.Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done n Well Destruction ❑ Well Diameter Sealing Material (top 501 {I�` Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Lavailable within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of Irving units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal LDistanceto nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size _ FILTER BED ❑ Distance to nearest: Well Foundation Property Line LSEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line { ✓)SP-SAL PONDS 4r` 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,I shall employ persons subject to workman's compensa- tion lawMInspection The appr all requi inspections. omplete drawing o verse si ' Signed Tide: V Date: 7 �S ` �Q FOR DEPA ENT USE ONLY � ,.�, Q��t/ I Applica !N '\ Date 7_222_— � grea (7 LPit or Gy Date Final Inspection by Additional Comments: _72 4 ho♦• YUd�lr�ru.} yC- 7-)7 ( 111-6 v}r�l rrcvrovl -Lyci-i ri5 ❑ Stk 466- 1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Illlrrr... Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.- CA 95201 PLATE 11, Page 6 of 16 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMR NO. �_H 1324 IRW.10= In EH law