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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209)'466-6781 r PERMIT EXPIRES I'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaqui Loco! Health District. n Local Health District for a permit to construct and/or install the work herein described. This application is made compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joi aqun i Job Address &K 77 City Lot Size110 pM Owner's Name �^ ; Address Com' C s3 Z¢ Phone Contractor ss A� � 7✓n • ,fes r TYPE OF WELL/PUMP: NEW WELL ❑ License No._�� Phone WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION- '7 DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHET 173SEWER LINES DISPOSAL FLD. I �PROP. LINE FOUNDATION d9 AGRICULTURE WELL OTHER WELL a f -- / PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �. ID /l �Di omestic/Private Gravel Pack ID Tracy Dia. of Well Casing Y Type of Casing Specifications fI F1 Public 17 Other D Delta Depth of Grout Seal 4� I I Irrigation f—&Approx. Depth I-1 Eastern Type of Grout rface Seal Installed by r Repair Work Done ❑ Type of Pump f H p i State Work Done ` Well Destruction Well Diameter ! Sealing Material flop 50'I �j,n Depth Filler Material IBelow 50') I' TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I ! DESTRUCTION I t INp septic system permitted if public sewer is Installation will serve: ResidenceCommercial_ Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth `F EJType/Mfg n� PKG. TREATMENT PLT. ❑ Capacity No, Compartments T Method of Disposal - Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No - . & Length of lines Tot length/size FILTER BED �-�� ❑ Distance to nearest: Well ( Foundation Property Line SEEPAGE PITS I I Depth Size SUMPS S Number. - s: L� Distance to nearest: Well Foundation DISPOSAL"PONDS D Property Line. _- 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 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 such manner as to become subject to workman's compensation laws ofUCalifornia." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this ermit'is issued,'I shat!employ tion laws of California." p p y persons subject to workman's compensa- tion applica quired ' Complete drawing on rever side."- Signed X y . +=-�-Date: R DEPARTMENT USE'ONLY s t, y a Application Accepted by I r r �..'- Date I L ' MeaPit or Grout Inspection by f Date Final Inspection by j Additional Comments: Date .0 Stk-466-6781, Ll-Lodi-369- 3621 - �- < • _ r El Manteca 823-7104--w-- p-Tracy'=-835=6385--- Applicant - Return all copies to: Environmental Health Pe61it/Services-1601 E."Ha?alton Ave,, P:O:'Boz 2009;-Stk.; CA 95201 r' FEE A FO MOUNT DUE AMOUNT REMITTED CK �p� CASH RECEIVED.BYti EAT P, 3PERMIT NO. .. +-EH14-24fREV.iinSY � �j V- 17-1 /_ r7- } EN 1428 �A Q ` w o 0,o 0 TPj9 t:FO 1 y ..00 ! 1'7 15 .--r