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.�. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE,, STOCKTON, CA t Telephone (209) 466-67$1 PERMIT EXPIRES 1'YEAR FROM BATE ISSUED Application is hereby made to the San oaquin Local Health OiComplete in Triplicate) made compliance with San Joaquin county t for a permit to construct and/or install the work herein described. This application is I Loco! Health District. tY Ordinance No.549 for sewage or No. 1862 for well/ um l" P p and the Rules and Regulations of the San Joaquin k Job Address City Lot Size_1 LTA-1P-�� PM Owner's Name Address Contractor C e l Phone TYPE OF WELL/PUMP: Address , NEW WELL License No.�g Phone Lv; PUMP INST X, WELL REPLACEMENT ❑ D -��__ ALLA"TIO DESTRUCTION lO DfSTANCE TO NEA'REST:Si=pTlC-TX141'--�-p � SYSTEM REPAIR,"® N ❑ " —� SEWER."L'INES ""„-� �-3--�' OTHER ❑ FOUNDATION A 7----- bISPOSAL FL-D`-��•,9&,,�1 AGRICULTURE WELL "`PROP-I:INE— C9�� f I OTHER WELL INTENDED USE: : TYPE OF WELL � PITS/SUMPS ❑ Industrial PROBLEM.AREA CONSTRUCTION SPECItiC_ATIONS p�Open"Bottom ~—~— ' Domestic/Private ❑ Manteca °' Dia. of Well Excavation ❑ Gravel Pack Dia. of Well Casing rr ❑ Tracy T /� ` f 1 Publio (� Other Ype of Casing �,� i ! Irrigation 71 Delta Depth of Grout Seal Q Specifications —.-Approx. Depth I ] Eastern f Surface Seal Installed''b Type of Grout Repair Work Done ❑ TYpe of Pump � �_ Y Well Destruction H.P.- -1 .� f " �` _ © Well Diameter "I State Work Done Depth —Z\,.Sealing Material (top 50.) t� 4t` ' p �.3 Filler Material (Below 50'1 TYPE OF SEPTIC—WORK: NEW iNSTALLAT10N,1""I REPAIR/ADt}1TION-1-1 rDESTRUCTION I 1 (No Septic F Installation will serve: + P 1c system permitted if public sewer is VJ ' Residencevailable within 200 feet:) f CoCommeFcial� Other-*~ a Number of living.units: �: — ., a Number of bedrooms Character�f soil to:a depth of 3 feet- SEPTIC eetSEPTIC TANK ` # --`yh �" t ❑ TYpe/"Mfg �- Water table.depth PKG.:TREATMENT PLT. ❑ :Y, Capacity-7 No Compartments r Distance to nearest: WellMethod of Found lion Disposal ^ } -- �_-_ Property Line LEACHING LINE ❑- Na. i yLength of lines FILTER BED Q Distance to nearest: Well Total length/size s Foundation Property Line 4 SEEPAGE PITS .I'I DepthSi ) - ze r Number SUMPS Cl Distance to nearest: Well DISPOSAL PONDS L7 #_ Foundation Property Lin herehyrcer—, that I havg.preparedithis 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 signature certifies the following: "I certify that in the performance o�the work for which this permit is issued, I shall employ persons subject to workman_'s compensa- tion �' tion laws of California." The applicant m9f call for all required inspections. Complete drawing on reverse sid Signed X rki '-"' - � � Title: �s Date: a� + FOR DEPARTMENT USE ONLY i Application Accepted by ��^ � Date . r Area p Pit or Grout Inspection by C.�� Date Final Inspection by ' : Date Additional Comments: ❑ Stk 966-6781 p LodR" 369-3621 T 13pplicant `Mariteca 823-7104 ❑ Trac y 635-63g5 r` AReturn"all copies to: Environmental Health Permit/Services 1601 E.,Hazelton Ave., P.O. Box 2009, Stk.; CA 95201 i FEE AMOUNT DUE INFO 'AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO CASH . EH 13-29-IREV.rin51 J /� �-7 �G 4 EH 14-29 ` lJ - _1A/9