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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.ftff,'IZEL T ON A�E., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ��„�,�� /Application is hereby made to the San Joaquin Local Wealth District for a permit to construct and/or install the work herein described. This application is 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 alth District. J� Job Addressp City Lot Size 1 PM Owner's Name Z!L RE Address cZ.44 Phone M/ , ' i, rE� ^7 r� Contractor /9q AJe) // S .Address_ �alia1 4X i c e n s e No. �o Phone z� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONAZ� SYSTEM REPAIR L1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK —be- SEWER LINES DISPOSAL FLD. PROP. LINE 25 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !f ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing ✓37 � Domestic/Private _64-a-0Gravel Pack ❑ Tracy Type of Casing /Specifications _64-C1 Public / ❑ QTher 171Delta Depth of Grout Seal Type of Grout 1JTAty I 1 Irrigation Approx. Depth II Eastern Surface Seal Installed by—----- e!!AL=_Lf09 TE Repair Work Done ❑ Type of Pump ' H,P. 2— State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION f I DESTRUCTION l I f-No-septic system permitted if public sewer is available within 200 feet.) Installation will serve:. Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth d SEPTIC TANK ElTypelMfg Capacity fir, No. Compartments PKG. TREATMENT PLT. ❑ +<�,.Method of Disposal `S tl Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ h 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 n rules and regulations of the San Joaquin Local�`Health District. Home owner or licensed agent's signature c4xiiti 3efi ellfoli6wing: "I certify that in the performance of the work for which this permit is issued, I shall employ any person in such manner as to become subject 4t workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performadcer67,the work for which this permit is issued, I shall em�to'y persons subject to workman's compensa- tion laws of California." The applica o iI req 'ce � actions. Complete drawing on rev se side. 00 Signed X- -- "_' Y� + g Title: Date: &//4? FOR DEPARTMENT USE ONLYj. Application Accepted by CrIV pate Pit or Grout Inspection by / / I ' Date / �V Final Inspection by Date �a Additional Comments: j ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ElTracy 835-63851. Applicant - Return all copies to: Environmental Health Permit/Servicail♦1601 E. Hazelton Ave., P.Oi Box 2003, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ' +.EH 13-24 fREV,t i H 5) /��r EH 14-28 JJ / J