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%. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) 4R#��I H plic Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the � i plication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the RulesrtD e�an Joaquin Local Health District. /�,4 �t"J�(j�` r. Job Addfess t3 o 1 _ _ Citv Lot Size PM. '1 6Owner's -2')� P ?'d -c � L /t SA S'C Name - Address 1, Phone Contractor r 1.�a�^Address !No. 0 Jo Uoyt _s_`6 License Phone }3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ '3 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial - ❑ Open Bottom ❑ Manteca Dia. of Well Excavation of Well Casing �/D�{ia. �omestic/Private LJ Gravel Pack ❑ Tracy Type of Casing 4pecifications M Public C! Other F1 Delta Depth of Grout Seal Type of Grout _ I Irrigation —. -Approx. Depth I 1 Eastern weal Installed by ! _ /Surface Repair Work Done ❑ Type of Pump �� H. P. C i State Work Don Well Destruction [03 Well Diameter Sealing Material {top 501 __ l it ,'XJEW) egAli;:- Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I 1 ' DESTRUCTION l I Moj' eptic system permitted if public sewer is Installation will serve: Residence Commercial Other .0� available within 200 feet.) ) jl Number of living units:_ NNumk5�r"' bedsny_ms ��` Character of soil to a depth oi"�' eet o 4,; Water depth SEPTIC TANK ❑ Type/Mfg j' _Capacity table No. Compartments PKG. TREATMENT PLT. ❑-A- - Distances=to .'Wellr� '^,Foundtion Method of Disposal nearest~.;. Property Line LEACHING LINE ❑ No`&,Length of lines Total I ngthi)size FILTER BED ❑ D)stance ito nearest: Well Foundation ProIferty Line SEEPAGE PITS i I 4pth `� Size Number �istance SUMPS El Ito nearest: Well Foundation Pragerty Line DISPOSAL PONDS L) hereby certify that 1 have prdpared this application and that the work will be done in accordanbe with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Diltrict. r -A 0 Home owner or licensed agent's signature certifies the following: "I certify that i 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•Ltalifornia.'#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 taws of California." The applicant require t' ns. Complete drawing on re �srs�eside. { Signed X title: �- _ Date: 2 URS Application Accepted by Pit or Grout Inspection by Additional Comments: ❑ Stk 466-6781 . ❑ Lodi Applicant - Return all copies to t. EH 13-24 (REV. i i R 5) EH 14-26 DEPARTMENT USE ONLY Date Date Final Inspection by -'_�`rArea Ji.—Dater 369-3621 _ ❑ Manteca 823-7104 ❑ Tracy 835-6385 Environmental Health Permit/Services 1601 E. EHazelton Ave., P.O. Box"2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. 9/14 00