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'%. APPLICATION FOR PERMIT r./ - 4 5—/ / SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 - PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) L , .dtion 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 ...e 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. 9s�Y� Job Address V �1� IV M L City M rN Lot Size QU PM Owner's Name �i r S Ad ress S /r"1//' Phone 11.L eiit Arle�rx / K P {/1 Contractor Address U tf Iv License Nos0Z7b1 Pho - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER $ Jlmjc hba LVC41 DISTANCE TO NEAREST: SEPTIC TANK >— SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION 7`O AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION 3 fiK Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing k— Specifications /- Pl Public 171 Other Ll Delta Depth of Grout Seal 1'760 Type of Grout CCg1te r I I Irrigation 300-0-Approx. Depth I I Eastern Surface Seal Installed by C_AAx&Aie _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( i DESTRUCTION I PINo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living 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 Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size FILTER 8E O Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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 Diltrict. 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 taws of California."Contractors 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 applicant must call for all required in Com/pJ"a "drawing on reverse ssi ` p Signed X //� '� In J{ � 0,(� J G tC� Date: v Gi FOR DEPARTMENT USE ONLY Application Accepted by Date 0Area Pit Gro Inspection by /� 11 ��77 Date d Final Inspection by Additional Comments: _rf_,,MCa l7Z...A- /S� aF.�l' Y .,rd-, «�73 g'-x''22 �61Y'�C ltd•�ts Cotvt d[(r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca�81 -7104 ❑ Tracy 835-6385 �.z� .(wtiutYdL.f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE SCTfln'�t`N� NFO AMOUNT DUE AMOUN99T REMITTED C SH RECEIVED eV GATE PERMIT N.,O/. ♦ EH 14-al IPEV.vxs) /Or 1iO 7Gj V /7� —/,z` �/