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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209) 466-6781 St-AURED 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job AddressCity Lot Size PLA Owner's Name _1_.,1V7E /6 ddress Mr— Phone `dr - N 466 Contractor Address 1.�,1�.G� /Z)9License No.�`�Phone TYPE OF WELL/PUMP: NEW WELL.>a WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ � HER /n S❑ ' I DISTANCE TO NEAREST: .SEPTIC TANK �( �� SEWER LINES DISPOSAL FLO. PROP. LINE �q FOUNDATION � AGRICULTURE WELL �- :OTHER WELL PITS/SUMPS. A&I S INTkNDED USE -TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION !! )aIndustrial -❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Dom stic/Private >PGravel Pack ❑ Tracy Type of Casing r Specifications f'l Public ( i��/nOtther it Delta Depth of Grout Seal Type of Grout I I Irrigation ��✓_Approx. Depth 11 Eastern Surface Seal Installed by ' Repair Work Done''©�- .Vpe�fPurnH.P. i Stake Work Done_ �V Well DestrecFiort � rWeA Diameter-- -_" 1 s� 5eafing.lsAaterialofiaA_5U,1 ' r —FiiCe'r-Material-(Below 50;1 _�1+j r TYPE OF SEPTICJWt]RK:, NEWJLVSTALLATION I.! REPA'IIR/ADDITION I I DESTRUCTION F,1 iNo septic system permitted if public sewer is t available within 200 feet.) Installation will server' fie§ide ce Commercial_ Other l Number of living units: Number of bedrooms Character of soil to a depth of 3=feet:l r ` ' Water table depth } �- ss S_EPTICyy"TANK C1Type/Mfg1 .- Capacity r� J No. Compartments PKG. TREATMENT PLT. 1� I t Method of Disposal �l r A i (stance to nearest: Wel! �---Foundation Property Line N LEACHING LINE„„_"�2D QJ& Length of lines Notal length/size r •� FILTER BED � r,+'.© Distance to nearest: Well ' F undlation � Property Line II 'f i SEEPAGE PITS I I Doth f Size Y Number +SUMPS t yf 1 g e Ll Distance to nearest: Well Foundation Pilo party Line r DISPOSAL PONDS ❑ I hereby certify that I have prepared*this application and that the work will be done in accord`ance.witf� San Joaquin county ordinances, state laws, and rules and regulations of the Sa t-o'quin•L••oval-Health-Dlstrict” ---- --- -i !! f �.. Home owner arlicensed Agent's'. gnatu're�rerti�re'sCtflfallowingh"I certify that in the perfo� ante of the work for which this permit is issued, i shall not employlany person in sucfi=ma`nnar aiNto•becomwsubject:'.teo workman's comp�tron IwWs of California." Contractor's hiring or sub-contracting signature certifies the following: 'I certify thk in the performance of the work for which this permit is�issued,i shall employ persons subject to workman's compensa- tion la of California." , . --•-- �' ___ i} f The applicant r required ' s. Comoplete drawing on _S vers i, Signed G- X Title: _ ,�i Date: F FOR DEPARTMENT USCONLY Application ceepted by ,' l Date Area Pit or Grout I s ctibn bye:"j i'a Date Y'� =iAnal Inspection b Date Additional amments: +�# �f~ �C ,��Yt_ 2i 7�1 C_ `JG? Y ❑ Stk 466-6781 ❑ Lodi 369-36213 Fµ7O Manteca a23-7'114' ❑ TracyF635-6385 Applicant- Reiurn•-all-copies.to:-Environmental Heatth_Parmiti-Serviees-1601"E-Hzi2 fltoon'tAve., P.O. Box 2009, Stk., CA 95201 . ��'� ♦ E � ewe ry. 41�FEO AMOUNT DUE AMOUNT REMITTEO CASH RECEIVED BY DATE PERMIT'NO. a,EH13.241REV.i/»sl S r-��/) r I EH 14-26 V