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U APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 ❑ PERMIT EXPIRES 1-YEAR FROM DATE ISSUED RECEIVED lComplete in Triplicate) 11AR 0 5 4990 Appiication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work I � Sjation is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the RulepbrMgeg rr?19fh t�Vquin Local Health District, n ENVIRONMENTAL HEALTH DIVISION Job Address 'A`+• =,rneryl C.�r��ll+ r Dr . a- �,Ayl+Li/le City rUC Lot Size yQcN'_re,�i PMI , 40e_ ZC.tLC 4 Owner's Name J.m c Address C!o S fGQ�e �e� t� Vt1cr 5 5 Phone c - o,,- -F. CA `f-1 IIt Contractor /acs L r ear Address PO 6ax ri?)S SAn katytdn C&License No,gn 70m 0 Phoney/} ev, 3`11 T 14 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE j FOUNDATION AGRICULTURE WELL OTHER WELL ITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I I Itithighlrll i 1-1 Onnn Retfnm DIA. Of Will FMriaVltllnfl .-.6_IAG1le,6 Di11: of Wfl �I/H hr., !Rf Domestic/Private 15Gravel Pack Tracy Type of Casing C_ Specifications I'1 Public I-1 Other Cl Delta Depth of Grout Seal �_ fce`I- Type of Grouter LCI 'y+-_._ I I Irrigation Z12 ..Apprnx. Depth I I Eastern Surface Seal Installed by_A ,. Z,cr enLc �I1 r Acel _-_ Repair Work Done ❑1 Type of Pump H.P. State Work Done Well Destruction ❑' Well Diameter 41'Ac Sealing Material (top 50'1 neXi CCjeyl'1' carra� i Depth Z.O Fcr_* Filler Material 10elow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic systern permitted if public sewer is available within 200 feet.I, I Installation will serve: Residence_____ Commercial_ Other Number of living UnilA: 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 r Distance td nearest: Well Foundation Property Line r LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED i ❑ Distance to nearest: Well Foundation Property Line SEEPAGI= PITS t I 1 Depth Size Nytmber SUMPS Ut Distance to neatest: Well Foundation Property Line DISPOSAL PONDS ❑ • 4 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 Di3trict. 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: 1,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 applica— it call er all qui ed inspections. Complete drawing on reverse side. O t Signed X � �S Title: ' Si� Y Date: 3-1- 70 NT USE ONLY � Application Accepted b bate 3::- Area �� Pit or Grout Inspection by Date Final Inspection by Date I Additiorid Comments- ❑ Stk *-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant; Return all copies to; Environmental Health Permit/Service's 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I i FEE I ` INFO AMOUNT DUE AMOUNT REMITTER CASH CK RECElVEt)BY DATE PERMIT NO. . EHS3241REV.4ixs) // C/ EH tl-26 (S'(f �f