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APPLICATION FOR PERMIT Q NAY M E N ! ' SAN JOAQUIN LOCAL HEALTH DISTRICT R EC E I V EQ 1601 E, HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 JUN PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I:NVIRQNMENT E,11L.TI I P[ (Co iMA§L W80XW__-z Application is heiehy made to the San Joaquin Local Health District for a per � �Aaj cribed. This applica,ion ir. inane in compliance with Sari Joaquin County Ordinance No. 549 for sewage or N 1862 for well/ ump ulations of the San Joartuin Local Health District. §PE j Job Address q� 5 �r5�tl.K City�IL_(�r 7ati Lot Size Owner's Name �+el� 0[( Cd AddressPa &k 144 �AY�La�vil `'rte !�' hone"i.�-r'�.r(i�_1�}�_ ._-- Contractor �� Address U13- Gra1KlLicense No 5 Phone��i'G��C- �Z Tln TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION Cl PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 4 3 ln,A,%k rLln Fscl�$ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � }�' DISPOSAL FLD.__1*__ PROP. LINEdt' FOUNDATIONFLS— •AGRICULTURE WELL 101- OTHER WELL__rte- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I I Industrial CI Open Bottom l_I Manteca Dia. of Well Excavation-t_O�rvr r. Dia. of Well Casing f jjt. _ --_.. i I Domestic/Private I_i Gravel Pack A Cl Tracy Type of Casing G_ Specifications 1'I Public be Other 11leL�ellx.l 1-1 Delta Depth of Grout Seal _ (/��1�_.---- _ Type of Gr///o��ut '-._._ t I iniflation Approx. Oepth I I Easrern Surface Serrl Installed by t f V Repair Work Done U Type of Pump iJf1 11,P. State Work Done _ Well Destruction D Well Diameter Ia hr�s Seating Material Itop 50'1 ?t hO&1 ar10 Depth [167t'}' Filler Material (Below 501 —_ TYPE OF SEPTICWORK: NEW INSTALLATION I I REPAIWADDITiON I I DLSTRUCTION I I (No septic system permitted if puhlic sewer iS available within 200 feet.! + ' Installation will serve: Residence— Commercial_____ Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Ll Type/Mfg Capacity No. Compartments �_ 1 PKG. TREATMENT PLT,❑ Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines _ � Total length/size—______ Fit-TER BED 1=1 Distance to nearest: Well Foundation ___ Property Line_ SEEPAGE PITS i I Depth Size _ Number SUMPS 1.1 Distance to nearest: WL-11 Foundation Property Line . 1 DISPOSAL PONDS L7 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 Di vict. 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, t shall not employ any person in such manner as to become subject to workman's compensation taws 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 to workman's cornpensa- lion laws of California." T tie applicant calf for allZ01 red ' Lcfions. Complete drawing on rev fse side. i C/ lav Signed X Title: �l I L� bate: Lam(141 'l�••�b FOR DEPARTMENT USE ONLY r Application Accepted by J�ADate Area Pit or Grout Inspection by Date 1 i Final inspection by Date Additional Comments: F1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUI: AMOUNT REMITTED CK RECEIVED 6Y DATE PERMIT'NO, rr„a74tR[v.,,ksi .t 00 I(0� E�+ 14.76 w 1