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n APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 466-6781 ,.r, . .. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;.. (Complete in Triplicatel 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.: f 3� K � Job Address e ,y City ,.�C� of Sizex 108.7,13M , Owner's Name OPI s1 � Z J r_ Address, 642 14QAV�.- 4Vs Phone lm_'0!6 Cgntractor Pf. [ 2 /Address License No. Phone � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ `=PUMP INST_A.L_LATION'❑ """ 'SYSTEM-REPAIR ❑- —-OTHER OTHER-0-- DISTANCE ❑-DISTANCE TO NEAREST: SEPTIC,TANK;, z.,. SEWER LINES DISPOSAL FLD. PROP:f_INE FOUNDATION 4 ""- ` AGRICULTURE WELL _' _0T9E&-V'�1EL`Cr' � PITS/SUMPS INTENDED USE- TYPE OF WELL^_PR_OBLEM AREA_CONSTRUCTION SPECIFICATIONS i �"G� ❑ Industrial ❑ Open Bottom 4❑ Manteca Dia. of Well Excavation "� Dia. of Well Casin ❑ Domestic/Private ❑ Gravei-Pack '.- ,C1.Tracy TCasing - z - i ype of -- -.- — Specifications ❑ Public-- ❑ Other ❑ Delta Depth of Grout Seal 'J 4 s t f _ Type_of_Grout - - , ' ❑ Irrigationpprox, Dep th ❑ Eastern Surface Seal Installed by a ,ZRepair Work Done ❑ Type of Pump H.P, - Staie Work Done Well Destruction ❑ Well Diameter Sealing Mate aE )top 50') �' Y Depth Filler Material (Belouir_50') V s.? TYPE OF SEPTIC WORK: .NEW INSTALLATIO REPAIR/ADDITION ❑ DESTRUCTIONXT (No septic system permitted if public sewer is r' available within 200 feet.) ' Installation-will serve: Residence il!! Xommercial.= Other ,4 Number of living units: �� Number of_bedrooms Character of soil to a depth of 3 feet: tt f!i4174r, Ala Water table depth SEPTIC TANK _ ❑ T�e/-Mf t Ca act �y�� " �._ _ Y.p__ 9 P tY �"vv Q No. Compartments Vi PKG. TREATMENT PLT. ❑ . � � Method of Disposal me-s' y Distance to nearest: z Well Foundation Property Line LEACHING LINE No. & Length of lines. Total length/size—,('00 " FILTER BED EDDistance to nearest: F Well j Foundation-.-�-.. Property Line V- rA, SEEPAGE PITS ❑ tDepth f0 -Size Number' ! SUMPS ' Distance -to Aearesi:" Well Foundation 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, an 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 f 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: "I certify that in the perfoimance of the work for which this permit is issued, I shall employ persons subject to workman's compen_sa- tion laws of California." The applicant must call f r all required in actions. Complete drawing on reverse side. Signed X - ... ` G Title: Date::3,"- FOR DEPARTMENT USE ONLY �` x Application Accepted by Date ? Area Pit or Grout Inspection by Date Final Inspection by Date-- - �5 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca "823-7104 ❑ Tracy 83546385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009;Stk., CA 95201. f FEE 4 . + INFO AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT NO. + EH13-24(REV.I/8!i) 36,5 �-7` EH 14-26 70 00 'y C CY -"1, `_. Z-�9rla , 5;,l-5 Ta, s Ss- air-7/77