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APPLICATION a-FOR,PERMIT SAN JOAQUIMLOCALiHEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Tele�hbne (209} 466 679i"' q ;.•t� +•rsr wn nt PERMIT EXPIRES,1 YEAI# FROM,DATE..ISSUED,, . A + k �' t i :€f' "1 i!" i '•-,.�C_01Tl��et8,If1 TfIplICBte} � :'K$ $ ,.t'i" �`L?`i3�i'36''I`i1�C�C7f?)" r1 '( 1r, 4C Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herewdescrilied.'This'applicatibn is made in compliance'with San Joaquin County•9rdinance,No:;549 for sewage or•No:1862 for well/.putihp-and-the Rules and-Regulations of the San Joaquin LOCdI Health DI5tfICt_,.,? fi.} l [',+;y,syr_'� '�.:c0 �e�:s).. [.y '1 f1 V i� !^isi;F {FI$ I� a.4 "3s- !0 101c s'y;., XI' L13Pt�Y e..9 /�'� Iw;. r is-1�>�l ii" '� ,`1 '" �4 -!,'�,rt f• �€ �' ��- y�y1i _Ke �14Y ".i��,'� "I 'i�e� �1'4 fFf`rt�•i'r3 � y Job AddressCity �!llfLot Size J PM •-:.. -.. _.. .ter _ -. ._ _ rr��1 f� �,�`�' •�. _ _ Owner's Name +o��M� ' Dr�i4,� Address �� /t/- p Phone �.� ` Contractor's NameAS46'AMt &yj 0 ed License No. 1~ Phone • +7.—r�P TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ •;' DESTRUCTION ❑ PUMP-INSTALLATION SYSTEM REPAIR ❑ OTHER ❑' DISTANCE TO NEAREST: SEPTIG,TANK SEWER LINES DISPOSAL-;FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL: tOTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom- ❑ Manteca Dia. of Well Excavation Dia..of.Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other. ❑ Delta Depth of Grout Seal Type of Gout ;• ❑ Irrigation - --Approx. Depth ❑ Eastern Surface Seal Installed by f ; Repair Work Done ❑ Type of Pump S W43 H.P. 2 State Work Done Well•Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 507 ,TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ 1 N septic system permitted if public sewer is' ' " availabla within 200 feet.) Installation will serve: Residence Commercial_ Other * Jam+ Number of living units: Number of bedrooms Character of soil to a depth:of 3 feet: ° a w Water table depth (� SEPTIC TANK ❑ Type'/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well' Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED '❑ Distance to nearest:.. Welll Foundatlon H Property Line SEEPAGE PITS ❑ Depth Size Number �- SUMPS ❑ Distance to nearest: Well Foundation Property Line - �+ DISPOSAL PONDS © 5 �l 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 District.- Home owner or licensed agent's signature certifies the following: "I certify that in the perfotmance 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 eerfrfies 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 applicant FN.St call f r all re fired in pecti s: ornplete drawing on re verse side. Signed X Title: ate: I DEP 114TMENT USE ONLY ,. "Application Accepted by Date Area a .,Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: ❑ Stk. 466-6781 ❑ Lodi--369-3621 ❑ Manteca- 82.3-7104 -❑ Tracy 1' i - 835 6M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,,CA 95201, ' :_ s FEE AMOUNT DUE J AMOUNT REMITTED CASH RECEIVED BY '' DATE' PERMIT"NO: r a NFO EH 13.24 IRE. IDM � ..t,,..1. I� EH 1428 {