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C/l� � Dc✓_nC./ tia.�. pyr,. S t.)� �-'«x:L�.(-,- ',727 LD r_a-r� /f O r.,c,�II �a�i'� V�V'� APPLICATION FOR PERMIT .• ��3 — Cvxcw.fie /&?--WSAN JOAQUIN LOCAL HEALTH DISTRICT C al 014 4..mai. p,t, L.� 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 468-6781 PERMIT EXPIRES I'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor 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. d .lob Address M City ST/Crt! Lot Size PM Owner's Name 7 at 41W60 f e Address Phone Contractore-IF Address `^ License No. Phone TYPE OF WELL/PUMP: / NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PzY PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia..-of Well Casing /f 1-1Industrial ❑ Open Bottom ❑ Manteca." Dia. of Well Excavation ing \AVS ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy i Type of Casing Specifications F1 Public t 1=1 Other ❑ Delta Depth of Grout Seal Type of Grout --. I I Irrigation I —.-Approx. Depth- I I Eastern-� �W Surface Seal installed by �+. Repair Work Done ❑ Type of Pump H.P '^ State Work Done Well Destruction ❑ Well Diameter Sealing'NMaterial (top 50')- # Depth Filler Material (Below 501 -" "--- --- vv TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION l 1 DESTRUCTION 101iNo septic system permitted if public sewer is; .-- -.:-"— ---�- µ- -available within 200 feet.) Installation will serve: Residence— Commercial Other € i r i Number of living units: Number of bedrooms , Character of soil to a depth of 3 feet: Water table depth SEPTIC TANKd ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ " Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BEP i ❑ Distance to nearest: Well " Foundation 'Property-Cine I 1 i SEEPAGE PITS 11 Depth Size _ Number SUMPS Cl Distance to nearest: We11 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 ctiunty ordinances,-state laws, and rules and regulations of the San Joaquin Local Health District. t 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 I 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:"4 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." The applicant must call for allrequired inspections. Complete drawing on reverse side. r Signed X Title: _ _ Date: S- jo, — DO'4 I FOR DEPARTMENT USE ONLY Application Accepted by /�r Area I Pit or Grout Inspection by Date Final Inspection to Date '7 /o �f Y 3 � Additional Comments: ? j ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca 823-7104 Tracy 835-6385 Applicant plicant - Return all copies 2�, nvironmental HealthLPermitt//Services 1601 azeltor/�Ave., P.O. Box 2009, Stk., CA 95201 A)a i—C I/ we P r f �>,.y�. .d7 Yt•+.[�T i stn. .I� — 6/I2-1$7 J MOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. [!2A / (C,ASH )+.EH13-24(REV.1/x519 3� 3s'vv l!/a� 5 �p�� { (z�V EH 14-2e g ! L