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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` ` 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) SINS, e^-' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor herein described-1,N 'pplication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulatioins of'the an Joaquin Local Health District" ��y a?��l leg le-)!a —zl_ < s Job Address -1 (J_ e t� -.-_ City 11► Lot Size PM Owner's Name e a c a A eltO ZD Address ofn , ffl.Z � hone ' • I Contractora?Address 50 l�.c7Z[,f. Le License No.5,9 Phone ?—/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑, DESTRUCTION ❑ PUMP INSTALLATION 0, SYSTEM REPAIRS 4' * OTHER E] DISTANCE TO NEAREST: SEPTIC'TANK " SEWER LINES _ DISPOSJL- FLD. PROP. LINE FOUNDATION AGRICULTURE WELD OTHER WELL PITS/SUMPS it INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 ❑ Industrial ❑ Open Bottom ❑ Manteca - Dia. of Well Excavation Dia. of Well Casing V ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications a F] Public F1 Other F1 Delta Depth of Grout Seal Type of Grout — XIrrigation _Approx. Depth i I Eastern Surface Seal Installed by f;—T Repair Work Done; $ -Type.of_Pd'm_p_-.` —9— H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') i Depth Filier Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted it public sewer is + available within 200 feet.) Installation will serve: Residence 'Commetcial_ Other `t Number of living units: Number of bedrooms (w Character of soil to a depth of 3 feet: Water table depth " 1 SEPTIC TANK ❑ T e/Mf ✓ - "� '• `- YP 9 y Capacity - •" No: Compartments •" PKG. TREATMENT PLT" ❑ r Method of-Disposal Distance to nearest: Well . k ,Fouri`dation Property Line LEACHING LINE ❑ NO. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any parson 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applica st call for all req d ins ions. mplete drawing on reverse side. Signed X Title: e4 S Date: FOA7RTMENT USE ONLY Application Accepted by �'/' Pell Area Date � R Pit or Grout Inspection by Data Final Inspection by, f�`t Datek-6--ff... M Additional Comments. ��'' I ❑ 5tk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE N INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24[REV.+i x sl 3�`l.7[/ gq— ',3( 1 EH 11-28 ..... [� .� k