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,.� t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. 1 AZ�LTON AVE., 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 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, Y� Job Address 710_ /� Y � �s0 City Lot Size � � PM tOwner's Name / l Address l� /`Y �� _ Phone i Contractor S 'Address License No. 0 0/ Phone Zi— TYPE TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ es PUMP INSTALLATION 7q SYSTEM REPAIR ❑ OTHER D J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESf=�� DISPOSAL FLD.�' PROP. LINE FOUNDATION IZ AGRICULTU1iEJjWEL-L--±�0:r-HfR WELL-_._9i�-------'tTSYStJMPS �INTENDED USE USE TYPE OF WELL PROBLEM AREA •CONSTRUCTION SPECIFICATION ;J 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dia- of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �&0 I \ , V f i Public ❑ Other i f] Delta Depth of Grout Seal y�fff� Type of-,rout I I Irrigation 12ZOApprox. Depth I I Eastern Surface Seal Installed by 4414 1,1!; r x� Repair Work Done ❑ Type of Pump - H.P. State Work Donee i C� Well Destruction ❑ Well Diameter Sealing Material Itop 50'i �1 Depth Filler Material kBelow 501 TYPE'OF SEPTIC WORK: NEW INSTALLATION i-1 REPAMIADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) f Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms tI 3 Character of soil to a depth of 3 feet: ; Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Gti PKG. TREATMENT PLT. ❑ Method of Disposal _ Distance to nearest: Well-_ Foundation Property Line LEACHING LINE ❑. No. & Length of lines Total length/size _ r F ILTER BED ❑ Distance to_nearest: Well ft' foundation Property Line SEEPAGE PITS ' [ I Depth Size Number '^ �• k SUMPS D Distance to nearest: Well t foundation Property'Lirie DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wlPbe done in accordance with San Joa'quiA.cbuntylordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. `� i i r Home owner or licensed agent's signature certifies the following: "I certify-that in the performance of the work far swhich_thirpermit'is;issued�l 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 shalt employ persons`subject in workman's compensa- tion laws of California." i I{.f i�j s , t I ; The applicant st !' Ih wired " . Complete drawing q'n rev rr:a_slde=• Signed X Date: ' FOR DEPARTMENT USE QffLY Application Accepted by v t r Date '� I Area Pit or it Inspection by Date Final Inspection by Date� � ZA Additional Comments: - — i D Stk 466-6781 D Lodi 369-3621 © Manteca 823-7104 i ❑ Tracy 85 �� Applicant turn 4 copies too: iroprpe H h Permit/Se ices 1601 E. Hazelton 009, Stk.,CA 95 ii �l = _ __ _ ~ INFO �? OUNT"pUE AMOUNT REMITTED CASH ,RECEIVED,B� PATE PERMIT NO. rte, +.EH 13-24 VIEV.I/M51 EH 14-26