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I APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE:,.STOCKTON, CA Telephone (209) 466-6781 rMFj � PERMIT EXPIRES 1-YEAR FROM DATE ISSUED ��/�� i (Complete in Triplicate) $� MAR:19 1gg1 Application is he!eby made to the San Joaquin Local Health District for a permit to construct and/or install thp 4W46MC icationis made in compliance with San Joaquin County Ordinance Nb. 549 for sewage or No. 1862 for well/pump and t sZ4,9 P n Joaquin Local Health District. f ��pL DINION Ofd �7 I I L , S i DC,V SioCk� Job Address t� -Cit r �rf 1 1 �'e. „ .�ti�l.�,a!�, ,., ...,- �_ y � Lot Size PM 11,i r I 1 (7 } 12od &J lir) Owner's Name V J °'ti IIne—, Address .[,p_0-._� N•� Sf�+�'�/tsda�`ao t�pOlC� Phone 43 !+�-. 5- Contractor_ tt Address �C n CA gg53$- E�(LQ�_-6'-1� 14 S + �" License No.Cs7—�l�iSt{Sphone +S TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ 11 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER VfiMOriirO{`tnry `,3 weld DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manieca Dia. of Well Excavation $ i1%( Dia. of Well Casing Ina ❑ Domestic/Private X Gravel Pack ❑ Tracy Type of Casing 1c�� 1l L Specifications F1 Public 1=1 Other Cl Delta Depth of Grout Seal f+— Type of Grout (ter- - I I Irrigation -30TApprox. Depth l 1 Eastern Surface Seal Installed by Repair Work Dane O Type of Pump H,P. State Work Done Wet] Destruction ❑ Well Diameter Sealing Material (top 501 Depth q filler Material (Below 501) _ �1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I l (No septic system permitted it 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: P Water table depth SEPTIC TANK © Type/MfgCapacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal t� Distance to nearest: Well Foundation Property Line ALEACHING LINE ❑ No. & Length of lines I Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r ' V/ SEEPAGE PITS I I Depth Size Number SUMPS L1 Distance to nearest: 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, and rules and regulations of the San Joaquin Local Health Di?;trict. Home owner or licensed agent's signature certifies the fallowing: "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:"I certify that intheperformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." !i The applicant must call for all required inspections. Complete drawing on reverse side. Signed X fC5 1 int-^'- '-tx Title:_S'-^F�-� e�� fT� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date a Area n Pit or Grout Inspection by'' � Date2';3_7"2( Final Inspection by V�a I t��Qi 'Date—/ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteda 823-7104 ❑ Tracy 935-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 4 INFO AMOUNT DUE AL^M�O,UUN;T!lR��E--MITTED �I CASH RE'C'EIVED BY ��7 DATE PEAMIT'NO. . EH 432 (REV.1/N 5) 05i V 1 "f � EH [-~ � 1 .26