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n APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA , - Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED M (Complete'in Triplicate) is application is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This made in compliance with San Joaquin County Ordinance No.549 for sewage oY Noa1i362for well/pump and the^Ryes and Regulations of the San Joaquin Local Health District �:;, ' " ,-, �,. ,:�-• { s.r. f �y�! t{O titi-►L1t�Q 1� city STOGK-W k Lot Size PM _4 Job Address `- Y. , ; �- �:; � morti CA �t4S$3 - -Owner's Name(- License Address hone pINrJAT3�L�.a! otta0_ P +A IAI'A 3 Phone Contractor Address��-� �� -� _ hio. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ TYPE OF WELL/PUMP: OTHERS PUMP INSTALLATION ❑ SYSTEM REPAIR "❑ . y� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION t� AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS *� 11 Industrial ❑ Open Bottom Manteca Dia. of Well Excavation �- t'3 - Dia. of Well Casing ' Type of Casing -Five- Specifications ❑ Domestic/Private Gravel Pack ❑ Tracy yP _ "�I�'Qther" ❑ Delta: Depth of Grout Seal.- • �� - .Type of Grout �- 'I ❑ Public `. .,:� x ❑ Irrigation �OO+PProx. Depth ❑ Eastern Surface Seal Installed by H p State Work Done ="r Repair Work Done El Type of Pump f f r ! ►� Sealing Material atop 50'1 Well Destruction ❑ Well Diameter: 9 # Dept t Filler Material (Below 50'1 d tTUi2. r1f (.�r�. p . TION ❑ INo septic system permitted if public sewer is TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION p DESTRUCTION available within 290 feet.} f Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms t Water table depth ry Character of soil to a depth of 3 feet: r Capacity ' "• No.�Gompartments SEPTIC TANK ❑ Type/Mfg rj I PKG. TREATMENT PLT. ❑ t it Method of Disposal r Distance to nearest: Well W� Foundation Property Line i -� Totallertgth/size# LEACHING LINE ❑ r'No.-&Length of lines _ �-, FILTER SED ❑ Distancekto nearest: Well Foundation P%Line SEEPAGE PITS ❑ ,Depth_-- - - Size Number Property Line t SUMPS �. ❑ �Distance.to nearest: Well Foundation �� p �'tY - t ]� DISPOSAL PONDS ❑ 1 ' 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 t rules and regulations of the San Joaquin local Health.District. f Home owner or licensed agent's signature certifies the.foilow-ing: "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."Contractors hiring or sutrcontracting signature I certifies the following: '9 certify that in the performance of`the wo�k`for which this permit is issued,I shall employ persons subject to workman's compensa tion laws of California." �1 The applicantust ca far all required inspections. Complete drawing on reverse side, 41 U_� atTitle: i 4� vL Date: l Signed `` �4 R DEPARTMENT USE ONLY I Date Area Application Accepted by Date Final Inspection by - Date 'Pit or Grout Inspecti by .ti Additional Comme �� led o- - 6 d "• p.Stk-•-466-6781 —D-Li di-'369-3621"�°"-❑"Mahteca"1123-7104 'Cl racy 83 Applicant- Return all copies to: EmArorimental Health Permit/Services 1601 E.}Hazelton Ave.,-,P.O. Box 2009, Stk., CA 95201 ti > r,. 4 ,. ,A � .• FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 9Y DATE' PERMIT NO.' " INFO ' + EH 13-24 4REV.1>a 5) 35 . Q EH 14-26 .. . - �,.. Z « y��"K..- ",.• - I