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y I T APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E:`,HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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 Distri %_75 A-1 , Job Address 0�/% /� j/ JI?b city Lot Size PM FOwner's Name PETS lad�/�iAI Address c �� ,/ n Phflne _� 7 Gvy41 �' ContractorAddress ✓ A"/s,Ge2 se XZ2License No. Phone -- Z TYPE OF WELL/PUMP: NEW WELL ❑ -:`.4W I_L`�EPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 1 SYSTEN!_REPAIR OTHER © _ [SIS ANCE TO NEAREST: PIC TAMC^ SEWER,LyN DISPOSAL FLD. PROP. i FOUNDATION .fi' AGRICULTURE WELL OTHER WELL PITS/SUMP------------------------------ j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing S Q 2 7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Put blit ❑ Other ❑ Delta Depth of Grout Seal i r TYPe of Grout C f ❑ Irrigation ? —.Approx. D t4 ❑ East S F, Surface_S_eal Installed by z S L!J Repair Work Do re !❑ Type of Purgps r ,Pa State Work Done Well IDestructiori ` ;❑ Well Diameter Sealing Material (top 501) IT Depth Filler Material (Below So') _ )RE2&&&2VA J C'21 �r,A 4 e TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is `I i ' available within 200 feet.) W r stallaLion will serve: Residence _,Commercial_._Other, O -�' - ---Number-of-liVing units: -.-- Number-of bedrooms - -- - - - Ch laracter of soil WaTe�table depth 5l PTlC TANK r; ❑ Type/Mfg Capacity ' No. Compartments PKG. TREATMENT PLT..❑, Method of Disposal Distance to nearest:' ,Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BEp ❑ Distance to nearest:. Well Foundation Property Line SEEPAGE PITS[ %� ❑ Depth Size Number �y SUMPS L1 Distance to nearest: Well Foundation r{" - � Property Line }� DISPOSAL PONDS p I hereby certify that f have prepared this application and that the work will be done in accordance with San Joaquin-county ordinances, state laws,and } rules and regulatrofis,of the San Joaquin Local Health District. Home owner orIic jnsed agent's signature certifies the following: "I certify that in the performanoe of the work for which this permit is issued, I shall not employ any person.)n'such manner as to become subject to workman's compensation laws of.California."Contractor's hiring or sub-contracting signature certifies the foilovr' rig "I certify that in the performance of the work for which this permit is Issued,I shall emto tion laws of Califofnia." P Y Puns subject to workman's compensa- The applicant m all for all required inspections. Co4lete drawing on rave 'ode. 1 Signed Tide: v'�' Date: 2 o` F OR DEPART, E1 USE ONLY Application Accepted by �% !~- �` a-a0- I Date Area r� Pit or Groyt lnspecti 6n Date AL2t1Z Final Inspection by Z Additional Comments: ... Date-_7L Ell L7 Stk 466-678, ❑ Lodi 3� 1 ❑ ant 823-7104 ❑ Tracy,' Applicant- Return ail copies to. Environmental Health Pemxt/Servrces 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNTDUE AMOUNT REMITTED INFO COi4KSH RECEIVED BY DATE PERMIT'NO. + EH 13-241REV.1/e5)EH 14--16 s ^1 _log ' �b f