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APPLICATION,FOR PERMIT SAN JOAQUIN1OCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 4M-6781 PERMIT EXPIRES 1 YEAR FROM .DATE ISSUED 1.,4 0;4u � .:, >, `.":+i- .. <,.-(Complete in Triplicate) 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 corrlpliance 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:l0� t O;^ 3•x[3 i t;� �3` L3� u:C#'':s'. :'�t t: k r 'G a. >° t Job Address f�� . .F/�� ,�Or�d�/S -�CI STiC�CII tY Lot Size PM Owner's Name - Address _ _ _ Phone ! J�7. ..� „ . .3�/S ��- / l�s7xfesespfi`f # i Contractor's Name L![r/�� All Aelef7F.Il;°License No. phona 4142 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION ❑ PUMP INSTALLATION fie 11e-'MA SYSTEM REPAIR El OTHER ❑ ? DISTANCE TO NEAREST: SEPTIC TANK: ! SEWER .LINES-. ' _- DISPOSAL FLD.__ �PROP-LINE-��4a Gd;Q �r FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS e INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS w ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications fications Delta Depth of Grout Seal Type of Grout ❑ Public ❑"Other . ❑ Irrigation , -JApprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump sUa H.P. Llr State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') — NZLf/ON Depth -Filler Materlal (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r available within 200 feet.) Installation will serve: r Residence_ Commercial` Other € - •' Number of living units: � A Number of bedrooms Character of soil to a depthtl of 3 feet: Water table depth { SEPTIC TANK ❑ 'Ta/Mfg __ Capacity 1 No. Compartments PKG. TREATMENT PLT.❑ r g 1 Method of Disposal distance to,nearest�. W_ell Foundation I Property Line (� :LEACHING LINE _ ❑ No. 8. Length of lines Total length/size FILTER BED '-i❑`rte i wince to nearest: Well Foundation Property Line SUMPS SEEPAGE PITS ❑ EDepthe—.-Size, N4_ ,Founclatio`n Number L ❑ Distance to nearest Well perty Line, DISPOSAL PONDS El 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 x. rules and regulations-of the San Joaquin Loc at Health District. \ - - . . r 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 laws laws of California."Contractor's hiring or sub-contracting signature i 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- t` tion laws of California. - 3 ; The'applicant must call for allrequir d inspections. Complete drawing in r verse si Signed, Title: 4 Zi Date: FOR DEPARTMENT USE ONLY - Application Accepted by F Date V Are `F Pit or Grout Inspection b Date_ � _ Final Inspection by pat ~ar Additional Comments: ❑ Stk- 466-67$1 ❑ Lodi -369-3621 a ❑ Manteca 823-71 ❑ Tracy 835-6385 Applicant- Return hit copies to: Environmental Health Permit/Services 16DII E. Hazelton Ave., P.O. Box 2D09,.Stk., CA 95201 4' FEE `AMOUNT-SUE ' AMOUNT'REMITTED--- CK —RECEIVED-BY SATE'-`_..PERMIT'N0. t�---^—Y INFO ti CASHEH 13-24 x `+EH 14.26IREY.101831 }^ 3S k