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'4 f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL:I.ON-AVE:,, STOCKTON, CA Telephone (209) 466-6781 E 7, PERMIT EXPIRES TYEAR FROM DATE ISSUED > (Complete in Triplicate) APR 9 logo Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal[ I��Tj�j �p4i action is made in compliance with San Joaquin County Ordinance Na 549 for sewage or No. 1862 for well/pump and the Ru d E� u at,h1,�` Pt1�l�elrnl quin Local Health District. M' C�) rl 1 Il r ' Job Address a-rm Cit Size PM S.J Owner's Name - W. r�• Ltx .�!►f,er Address M94 �Lt 11Mt.NL! 0,79A— Phone 710 i � Contractor Address—._ /14 7 License No` O Z 373 Phone 466— 6Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR 1-� OTHER ❑ a DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES f DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL i OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy = Type of Casing I . Specifications ❑ Public ❑ Other ❑ Delta !� Depthtof,Grout Seal Type of Grout --� \ mss, r — i I plrrigation YP .Approx.pDept�sfe d$r�_ce/}5eaiylnstalled by Repair Work Done C"T e of Pum (.t H.P. ! !7i State Work Done dir ea1AC4.gfXA9Is y Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION f I DESTR{+UCTION I I (No septic system permitted if public sewer is available within 2D0 feet.) Installation will-serve: Residence Commercial— Other Number of libirig unidumber umber of bedrooms Character-of-soil to.a.depth-of-3 feet.—r-, SEPTIC,TANK ❑ Type/Mfg !Capacity1 .b.Va_ !' No°Coritpattiiierits' i PKG. TREATMENT PLT. 1711 I- Meth od of Disposal Distance to nearest: Well Foundation— 1" Property Line --r' L4r } - LEACHING LINE ❑ No. & Length of lines T6fal-grF06/size FILTER BED ❑ Distance to nearest: Well Foundation €ia't�lproperty Line SEEPAGE PITS I I Depth Size 1 _ Number F SUMPS 1.1 Distance to nearest: Well Foundation Property Line � DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with'Sa`n Jefaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed pen's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall not employ any person in mann r as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the followi : "I certify at in th rfor a ce oft rk for which this permit is issu4d-1•shall.employ persons subject to workman's compensa- tion laws of Cali rnia." c The applicant ust call al require ins wing on rever e. "� l Signed X itle: f � Date: FOR DEPARTMENT USE ONLY Application Accepted by " Date ! Q Area T Pit or Grout Inspection by Date Final Inspection by Date Z t Additional'Comments: •❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 l Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 114-26 EV.iiHaf O X37