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gyp, /�� t APPLICATION FOR PERMIT ` II SAN JOAQUIN LOCAL HEALTH DISTRICT E-LTON AVE.,.STOCKTON, CA R1601 E.'HA2 y rl Telephone (209) 466-6781 to r I � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � 7, ': is s omp I (Clete in Triplicate} ` t,T1'I`- � ,. .I ,..: .• ;. Application is hereby made to the San Joaquin Local Health District far a permit to construct and/or install the work herein describedt�This. made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/Pu i P and thb Rules and R�u� vRiof1 Local Health District. '7 Lot Size PM Job'Address x"q.0,/ City rGl � o �Idfess (1 � Owner's Name Phone/ �� `�� L It ?6Address ! License No.UL�cr—f�Phone L 6 Contractor t TYPE OF WELL/PUMP: [NEW WELL ❑ - -VVELL REPLACEMENT ❑ DESTRUCTION ❑ / PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ Q' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS - ^s- G` ;INTENDED USE TYPES QF,WELL PROBLEMAREA:- -C NSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ .Industrial ❑ Open Bottom Di ❑ Manteca a. of Well Excavation of Casing Specifications ` - ❑'D estic/Private ❑ Gravel Pack ❑ Tracy Tye Type of Grout Public ❑ Other �I ❑ Delta Depth of Grout Seal 0 Irrigation ---Approx. Dep Eastern Surfa Seal Installed by Q Repair Work Done Type of Pump ��`�PJ H.P. State Work DoneIF E Well Destruction-,--'0- Well Diameter ter Sealing Material (top 50'1 E ° fi Depth Filler Material'iBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Lla Nailabpeftwsithin ystem permifeettted if public sewer is !Installaton will serve: Residence Commercial — Other �NI t umber_of living units: Number of bedrooms � ,�.� !( _E 1 Water table depth IFCharacter of soil to a depth of 3 feet:'"t _ SEPTIC TANK ❑ Type/§Mfg I Capacity No. Compartments l f- Method of Disposal E PKG. TREATMENT PLT. ❑ t DistanIce to nearest We1k�-- F dation Property Line P ii ZA LEACHING LINE L1 No. & Length of lines Total length/size FILTER BED ❑ Distank a to nearest: Weli Foundation Property Line SEEPAGE PITS EI Depth Size Number I I SUMPS ❑ Dista ce to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i I:hereby certify that I have prepared'I this application and that the work will be done in accordance with San iJoaquin county ordinances, state laws, and rules and reguI ti a San Joaquin Local Health District. j " Home owner icensed a nt's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ a person in such nner as to become subjec workman's compensation laws of California."Contractors hiring Or sub-contracting signature `• certifies a following: "I ce that'in the or an of ffie work for which this permit is issued,I shall employ persons subject to workman's compensa- tion la s of California." side. The a plicant f all req 'e plate rowing on revs !I. Title: 0" Date: A41 Signed j C) FOR DJEPARTMENT USE ONLY U Date '""� Area Application Accepted by i Date Final Inspection by Date Pit or Grout Inspection by Additional Comments: -❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 . ❑ Tracy 8354MM Applicant Return all copies to: Environmental Health Permit/Services 1601 E.Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I CK RECEIVED 8Y DATE PERMIT NO. INFO AMOUNT DUE AMOUNT REMITTED CASH + EH 1124(REV.1/8 5)) EH 1428 •J t