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APPLICATION FOR PERMIT R�C�'� ❑ SAN JOAQUIN LOCAL HEALTH DISTRICT 2 t9�5 HAZEL TON AVE., STOCKTON, CA 160? E Telephone (209) 466-6781 Dns d•-• PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, kk Job Address {J 3 L• 1 r , City T t�,! Lot Size c 100 /�,t� PM Owner's Name - 'T td t1p. 100 SDi1-n (-14-F�K6r_ Lo - —. Address Phone Contractor G�a^�0� 1[ 06 Address YQ�O Q 14�E (J11, CLyIJ R qtr r , �l TYPE OF WELL/PUMA: NEW WELL FJLicense No. 'l � ` 3 PhJ115 l�'rr�•� WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ r - DISTANCE TO NEAREST: SEPTIC TANK OTHER OA14ve^� G� SEWER LINES DISPOSAL FLO. PROP. LINE ( ,- k Will FOUNDATION AGRICULTURE WELL w INTENDED USE OTHER WELL PITS/SUMPS _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 ED Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �. Dia. of Well Casing ❑ Domestic/Private �'Gravel Pack ❑ Tracy T U C_ N El Public Type of Casing Specifications ��❑�Other ❑ Delta Depth of Grout Seal ��S ❑ Irrigation b n Je pprox, Depth Ll Type of Grout 60^1 �;r Surface Seal Installed by.jlE/�QI� ` epatr Work bone ❑If Type of Pump _ --�H. Well Destruction ❑ Well Diameter � Sealing Material /top 54') State Work Done Depth 30 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION L-I DESTRUCTION ❑ (No septic system permitted if public sewer Installation will serve: Residence Commercialavailable within 204 feet.! - � Other is { Number of living units: Number of bedrooms Character Of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity No. Compartments Distance to nearest: Well Method of Disposal Foundation Property Line LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: WeltTotal length/size Foundation Property Line�- 1 SEEPAGE PITS ❑ Depth 1 Size ❑ SUMPS Number 1 Distance to nearest: Well 1 DISPOSAL PONDS ❑ Foundation Property Line i 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 of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the Performance of the work for which this permit is issued, I shall employ tion laws of California." p y persons subject to workman's compensa- gg The applicant must call for all requ'a nspections. COmpie .drawing on reverse side. N Signed X t Title: ew t 2 $. Date: A E ONLY Application Accepted by 7 ~ Date�'�- — ��rArea Pit or Grout Ins I y '�jq�� Date---�- E_17Final Inspection by 6 Additional Comments: bate ❑ Stk 466.6787 ❑ Lodi 369-3627 IManteca 823-7104 JApplicant- Return all copies to: Enviirronn�me�nt-9I Health Permit/Se ices 760 E❑Hazelton Aye.P$O. Box W !I -f 30 f G' (JI o2?{ r y ry �", Stk.. Cf 95201 G�OlC1 "� FEE r e I IJ7 l r �N 1 vt C� 91�[f�rJ 4 € INFO AMOUNT DUE AMOUNT REMI !_D " CASH RECEIVED BY DATEPERMIT'NO. I + EH 13-24{FlEV.tiny EH 1a-28�