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tl �, APPLICATION FOR PERMIT A SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. ` /, , h Job Address �40 /{at�� /✓ City 6&V�r Lot Size PM it Owner's Name G AddressPhane !SL s g� F Contractor Addres >n ? License No. �7�`�s ', Phane33 Y- 'Y77-1 TYPE OF WELL/PUMP: �i NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMPiINSTALLATION � ;SYSTEM REPAIR ❑ _ OTHER ❑ DISTANCE TO NEAREST:SEPTIG-TAN K--=�SEWER LIMES- :_DISPOSAL-F.LD.. _ PRO•P�,LINE 't—15 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t LJ Industrial L3 Open Bottom EJ Manteca Dia, of'Well Excavation l�- Dia. of Well Casing to i Domestic/Private ] Graviel Pack L] Tracy Type of Casing PISpecifications 1�Q--&-� f-I Public f ❑ Other . C1 Delta Depth of Grout Seal ��CZ. Type of Grout I I Irrigation .- -- -__.Approx. Depth` LI Eastern Surface Seal Installed by CaAo 7AA4,J'L i Repair Work Done ❑ Type of Pump --y — H•P, S -1 € State Work bone 06 A✓ Well Destruction ❑ Well 6iameter _ .f Sealing Material,f3op.50') t, t Depth i� Filler Material (Below"-50 �n k TYPE-OF SEPTIC WORK: NEW'fINSTA'LLATION 11 REPAIR/ADDITION„[ Ii- DESTRUCTION l I (No septic system permitted it public sewer is • , , available within 200 feet.) Installation will serv_e:—Residence-�—Commerciaf_ Other Number of living units: I�Number of bedrooms t Character of soil to a depth of 3 feet:11 j '` Water table depth SEPTIC TANK 171Type/Mfg - Capacity No. Compartments t PKG. TREATMENT PLT. ❑ y Method of Disposal Distance to nearest: Well '"•f-•--Faundation Property Line r n LEACHING LINE ❑ No.11& Length of lines Total length/size r FILTER BED EJ Distance to nearest: Well Foundation Property Line " { I SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t 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 District. 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 siggature 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 of California." it The applicant must call for all re fired inspections. Complete drawing on reverse side. Signed X I Title: Date:4 I FOR DEPARTMENT USE ONLY , Application Accepted by III Dates Area Pit o rout nspection by -\ = G pate -3//-S-65-9 Final Inspection by Date —'J JZ� Additional Comments: �f ❑ Stk 466-6781 ❑ Lodi 369-3621 Ll 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 :11 47 FEE AMOUNT DUE AMOUNT REMITTED CK—f— RECEIVED BY DATE PERMIT-NO. INF ��tt''�� /M.7 CASH -�7 ///�� y�/ ♦.EH 11-29 IRfV.1./is 51 CV I� V��^� �� ` - 01 �-3