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APPLICATION,FOR PERMIT "7 Or? 376 I S SAN J � y� OAQUIN:LOCAL-HEALTH DISTRICT 1601 E. HAZE.T ON AVE.,,STOCKTON, CA Telephone (209) 466-6781 C-1-1 14 smPERMIT EXPIRES~1 YEAR FROM DATE ISSUED h (Complete r in,Triplicate), 13i'1ri;L..'i 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 Local Health District. and Regulations of the San Joaquin Job Address --/&3 !I -� •t. �.vTOS ��Irv�� „ :,l fttt�,'.'ti: ,,u n. c. ��L 0,,.`�T �, ` City. !rGrRLot SizeZ�2 c _ PM- Owner's Name D. �. Address Phone ContractorA&4 ddress'= -- ___ -- f _License No� .S,/'�2 Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION n SYSTEM REPAIR ❑ OTHER ❑ E ; DISTANCE TO NEAREST_ SEPTIC fTANK SEWER LINES DISPOSAL FLD.: PROP. LINE t. FOUNDATION AGRICULTURE WELL OTHER WELL , PITS/SUMPS _ INTENDED USE TYPE OF.1WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I \ ❑ Industrial i LJ Open Bottom I ❑ Manteca Dia. ofpe11 Excavation ^^'. — —Dia. of Well Casing ' ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy -Type of Casing r ; I t g SpecificaU`ons - ❑ Public ❑ Other ;I ❑ Delta Depth of Grout Seal Type of Grout v 71 Irrigation 1 r - --- 9 y —Approx. Depth ❑ Eastern surface Seal Installed by 1 f Repair Work Done ❑ Type.of,rump H-P. f State Work Done,___ I # Well Destruction ❑ Well Diameter _ � t' ' _ Sealing Material,ttop 50') r } t. 1i Depth Filler Material (Below 50') TYPE OP SEPTICIWORK: NEW INSTALLATIO REPAIR/ADDITION 0 DESTRUCTION C] (No septic system permitted if public sewer is - �� i ► - available within 200 feet.) r Installation will serve; Residence._ Commercial Other- i K ------ :�,•— ��-,� ,, r — �_ =tl 'Numbef of living units Number of bedrooms 1` t I t f 4 Character.of,soi, to a depth of 3 feet' A C` �`'� I j , Water table depth F SEPTIC TANK O Type/Mfg .� � �'t�-l!D (rj}L II �_,_�t_Cap bi y No. Compartments I� PKG. TREATMENT PLT. ❑ I� _j f } f Method of.Disposal j f Distance_to nearest: Well _-Foundation!y0 Property Line LEACHING LINENo.I �'C No. & Leng° th of lines �-`�O't� �T- �� Total length/size— FILTER ength/sizeFILTER BED L3Distancen to nearest: Well Foundation' T-Property Line SEEPAGE PITS j ❑ �Depth'� r Size t 1, Number .SUMPS I ❑ r0ist nce to nearest: Well .Foundation Property Line DISPOSAL PONDS 1 herebycert' that 1 have r pp l rfY prepared this application and that 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 signatuio certifies the following: I cert that in the + ' ' certify performance+f the work for which this pemlit is issued, I shall not employ any person in such manner as t o become subiect-to workmsn's-Gompensatibl 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}o workman's compensa- tion laws of California." t i _? -S 1 i u � : ; The applicant must rail f all r uired inspections. Complete drawing on reverse side. t Signed X � .�g !l/' t Title: Da ' te: FOR DEPARTMENT USE ONLY t y 4,. 3 _ - _ s 4 Application Accepted by Date � - r ! Aree • Pit or Grout Inspection by r pate Final Inspection by _ 1 Date Additional Comments: r ❑ Stk 4666781 ❑ Lodi 369-3621 .1 •O Manteca 823-7104 EJ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk-, CA 95201 r �t y AMOUNT DUE•�� AMOUNT REMITTED~ P.CK RE ii? INFO CASH~ CEIVED BY .,1DATE PERMIT'NO. �. EH 13-24(R EH 1428 EV.r _70,00-e st - :l i - ~r T`� uCY -7 � NI