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v APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED' (Complete in Triplicate) ' 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. :.2bw e ` iri3r, � E�'JSr7f/6 '<DT 4G'/2,EGO,Pd] Job Address1Z117J "RID city' L- Lot Size PM Owner's Name ROSE d4A11,45.e 4A) Address " 17g,29 DA/4//,S e Phone" Contractor FLoYD E . WkJ %OZ> Address &O-5-A), 4JL.Ly,<Al A t/5_License No..Y_25.3-7L. Phone 97 -:'TYPE'OF-WE=/PUMP:"'^""—'-'"""'NEW'WEL-L`O—WELAL REPLACEMENT'❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR:❑ 44il�pO7HER ❑'ems DISTANCE TO._NEAREST:_"SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIO- AGRICULTURE WELL r OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \\ E❑ Industrial Q Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing \` ❑ Domestic/Private ❑ Gravel Pack }4 ❑ Tracy Type of Casing Specifications `T ❑ Public ❑ Other "ACE Delta Depth of-Grout Seal Type of Grout tw ❑ Irrigation --Approx. Depth O Eastern Surface Seal Installed by Repair Work Done "❑ Type of Pump H.P. State Work [ Well Destruction 13Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ "(Na septic system permitted if public sewer is available within 200 feet.) fInstallation will serve:, Residence✓ Commercial_ Other Number of living units: Number of bediooms F Character of soil to a dept of 3 feet: C L.4 if ,rLh L Water table depth t SEPTIC._TANK%, —1; of //_p4e.--L Capacity 12.,90 No. Compartments � PKG.°TREATMENT PLT. ❑ ; Method of Disposal Distance-to-nearest: __WeIl--AjZ—!---Foundation—1_0 Property Line LEACHING LINE ' k i EP"Nof.f& Length of lines f "AW Total length/size DD:Y r FILTER BED ❑ ,Distance to nearest: Well. Foundation /d Property Line 3z i SEEPAGE PITS 'L Depth _ '� Size S4 Number SUMPS C] Distance Distance to nearest; Well 13Foundation_ 3D � 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 y rules and regulations of the San Joaquin Local Health District. 99 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." Contractors 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 ofCalifornia:" f The applicant must cll for all required inspections. Complete drawing on reverse side. z r _ Signed X S�. Aaol D � Title:" mac Date: G T y� 1 S I _ FOR DEPARTMENT USE ONLY/ a Application-Accepted byDate Tea �Z opit6l rout Inspection by Date z Final Inspection by DateI : i } Additional Comments: I❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835'6385 i 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 CK RECEIVED BY DATE PERMIT"NO. INFO CASH _ y + EFE'13-241 EV /a.i 57 C) '�,'r-,. � - - ��/ EH 1426 / Y