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1t: APPLICATION FOR PERMIT ! SAA: JOAOUIN LOCAL HEALTH DISTRICT �,�.• :;� � ��t,�� 1601 E. HAZEL T ON AVE., STOCKTON, CA4 4 Telephone (209) 466-6781 APR PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDEMJ 120hMFMAl,HE�ILTH s (Complete in Triplicate), Fc12Il/r17/SERVICES E: Application is hereby made!o the San Joaquin Local Health District for a permit to construct and/or install the work ht rein desar�ed`_TMs applfeetion la �i , " made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wellipump and the Rules and Regulattnns of the San�t>aquin i s r.� Local Health District. -+ - 5 str� x �•�+: t„P= j ^ .� L t°_[?{1 Cit 0-C Lot Size PM Job Address Y y5rr s ` % Owner's Name �'• Address r _ Phone' t Contractor Address License No.0 Pftone K jo s ' rTYPE OF WELL/PUMP: NEW WELL if. WELL REPLACEMENT ❑ DESTRUCTION ❑ x� Is PUMP INSTALLATION 7 SYSTEM REPAIR ❑ OTHF�t [3 DISTANCE Tp NEAREST: SEPTIC.TANK 1�+w SEWER LINES DISPOSAL FLD—ffia—PROPo LINE FOUNDA:'ION: _._� AGRICULTURE WELL OTHER WELL P1TSr5UMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECtF1C tt(t S ttf _r �❑f11 dustnal ;,.: 0 Open Bottom .J Manteca Dia,of Well Excavati Die of Well Casing L , " Dbmesuc/Private Gravel Pack L Tracy Type o}Casing Speeifieations- 1 ( r H } r 7 Aubh 7 Other F1 Delta Depth of Grout Seat Typa of Grout�� t f IA r Y �.1�/rn v I Irrigation pp ox. Depth I I Eastern ' Surface Seal Installed D Repsir Work bone ❑ Type of Pump _._ ' H.P._ State Worn DoneAa�Y r a r F Weft I3estructi+7n ❑ Well Diameter _— Sealing Material flop SO'I �,. Depth— -- Filler Material I&flow 501 _ 4s sato r '1 TYPE Of SEPTIC WORK: NEW INSTALLATION 1 1. REPAIR/ADDITION I 1 DESTRUCTION l I IND septic system permitted If public sewer rs available within 200 feet.) x ` lnstallstiun will s.^rve: Residence Commerciol Other _ f 1 Number of living units: Number of ottdrooms_ T, r` t Character of soil to a depth of 3 feet:_ _-_— - Water table depth ` SEPTIC TANK 0 TypelMlg _ Capacity_ No. Compartments441 PKG. TREATMENT PLT.L1 Method of Disposal Distance to nearest: Well� Foundation Property Line LEACHING LINE n No.& Length bf lines —__. __ Total length/size {>> rJ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line iub ss SEEPAGE PITS _i t Depth Number s SUMPS L. Distance ID nearest. Well _ Foundation Property Line DISPOSAL PONDS ❑ i I hereby certify that I have prt Dared thN application and that the work will be dont in accordance with San Joaquin county.ordinances,state taws ands l rules AnU regulationS of the Sari Joaquin Local Health District. L Moms owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued 1 shall n01 employ any person in such mannor as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature s -; Y. ee,tifies the}allowing:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subJect to workman's,campensa tion Jaws of California," / i The applicant st calf for req gd�tnspections. Cbmptete drawing en r arse side. ' — Title: bate.•.:/ � T Signed X�� / ----�� • FOR DEPA4TMENT USE ONLY ' Q � . Application Accepted by —��• ' ry��`, `"s"�-'"�� Date Area Pit or Grout Inspection by -- Data ` ?7 Final Inspection by Date Additional Comments: _C1 D � ' "' n %{ �� z' A xC:(' �t�fJ ❑ Sik 466.6781 ❑ Lodi 3d,3621 G Menreca 3.7104 0 Tracy 835.6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hezelton Ave„ P.O, Box 2009, SM., CA 55201 S _ - FEE AMOUNT DUE. AMOUNT "SH RECEIVED by DATE PERMIT ND� ] INFO _,. -..EHI]24tREV.1..er EH 14.26 . v II