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w � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin_Local.Health District for a made H compliance with Joaquin County Ordinance No:5q9 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin ] permit to construct and/or install the work herein described. This application is Local Health District. o u.}� r r Job Address 97 Y r,City ST :�-157AAI Lot Size 300' X PM Owner's Name J ,•+Jp Address / Motes a Cg.. Phone 9 f Contractor V 1 Address:. •�p 5� _ ��- � TYPE OF WELL/P MP: NEW WELL ❑ ' :. License No.�M-1?—Phone '7 WELL REPLACEMENT ❑ DESTRUCTION ❑ "PUMP INSTALLATION ❑ " - SYSTEM REPAIR ❑ .- OlSTANCE.TO NEAREST: _ SEPTIC TANK SEWER LINES OTHER ❑ DISPOSAL FLD. ` FOUNDATI0N/�„� AGRICULTURE WELL PROP: LiNE u OTHER WELL PITS%SUMPS ' INTENQED-IISE i. TYPE OF,V4/ELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS__ ~ -� ❑ lrfdustria! � �- -- - �- s „ a ❑ Open Bottom `Q Mantsca';' ©.Domestic/Private,n r '� Dia:.of Well-Excavation .. ""- ❑ Gravel Pack � --2 Trac 5 Dia” of Weil Casing ' ubhc ❑ Other YType. Casing. ❑ Delta Specifications " - -�-^- ,Depth-of-Grout'Seal. ❑ irrigation �.'- ' !Repair Work Done ❑ Type ❑ Eastern - Type of Grout . .q ype of Pum Surface Seal installed by WeII�Destruction �: H.P.' State Work Done _ ❑ Weil Diameter Sealing Mateiial (top 50') t f Depth r Filler Material (Below 50') _ - r TYPE OF.SEPTIC WORK: NEW INSTALLATION C REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if Public Installation will serve: Residence available within m feett P sewer is Commercial Other Number of living units: Number of bedrooms Q Character of soil to a depth of 3 feet: SEPTIC TANK X Type/MfgWater table depth L Capacity O' PKG. TREATMENT PLT. ❑ - No.�Compartments --Distance to nearest: yyep �, Method of Disposal N -- Foundation _(O� Property Line LEACHING LINE 1 K No. & Length of lines �� a n� FILTER BED Total length/size ❑ Distance to nearest: Well -18AJ6 Foundation---ZjD + - Property Line_ SEEPAGE PITS A Depth 1 SUMPS Size 6 " _ Number 7— O'°Distance to nearest: Welt' Odd �! DISPOSAL PONDS ❑ �— Foundation f Property Line---Ir—) I hereby certify that I have prepared this application and that the work will be done in accordance with San Jo-------------------- aquin 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 -mannecas to become subject-to -workmI compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performanceof the work for which this Permit is issued, I shall.e.m to tion laws a California." p y persons subject to workman's compensa- tion ' The applicant must.call for all required inspections. Complete drawing on reverse side. -6. -,Signed "ill-�-� r ,Title: ^ � GGr r Date: OR DEPARTMENT-USE-ONLY , Application Accepted bys Date Z�$ Pit or Grout Inspection ' Q[� Dat ma inspection by Additional Commen � DataIdZ f 0 Stk 466-6781 369-3621 ❑ ca Applicant- Return all copies to: Environ 823-7404 ❑ Tracy 835-6385 . a ealth Permit/Services 1601 E. Hazelton Ave., P.O, Box 2009, Stk., CA 95201 FEE AMOUNT DUE CK INFO AMOUNT REMITTED RECEIVED BY ZIA 13-24 DATE PERMIT"NO. +EH W26 fREV.1/8 51 /� 9