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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT,• 1601 E. HAZELTON AVE., STOCKTON, CAS Telephone (209) 466-6781 PERMIT EXPIRES.1 YEAR FROM DATE ISSU"ED F ' t a - (Complete in Triplicate) t •e d �.. ' ' 2 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal]the work herein described. This application is made in compliance with San Joaquin County ordinance No.649 for sewage or No.III&for wel]lptm p and the Rhues and Regulationaof the San Joaquin Local Health District I -. C. Offl' '1r - ,. .. ...., . , fir •1 .. Job Address'� C,N/rjAaITXA Lot$lye �O /Yr�tS PM Owners Name 44OW12 46,1165 tyx l Address j., :&:Z1' X47/— . _ _ . .• Phot!!/ Contractor's Na s License No. c02�/,DU - RITJ Phan t�+ TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ p DISTANCE TO NEAREST: SEPTIC TANKI OAllf SEWER LINES K10.JE DISPOSAL FLD.�. PROP. LINE c�0 r FOUNDATION /.'1 AGRICULTURE WELL_ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - ❑ Industrial ❑ DPW Bottom ❑ Manteca Dia. of Well Excavation No of Well Casing I I Domestic/Private Gravel Pact ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other i} ❑ Delta Depth of Grout Seal Type of ❑ Irrigation _-4pprox.'Depth ❑ Eastern Surface Seal Installed by Repair Work Dane ❑ Type of Pump' H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') . Depth -` - Filler Material 48elow 50.1' - - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION O DESTRUCTION ❑ (No septic system permitted if public-sewer is YYY N- tit avalable within 200 feet.) T Installation will serve: Resider be . t Commercial_ Other=-_.'e, i Number of living units:_ Numiier of bedrooms �w t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg `Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ 1 #� iMethod of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE ❑ No. & Length of IYga f' t` "�'�" Total length/size_ FILTER BED ❑ Distance to nearest: W61 Foundevon Property Line M a f SEEPAGE PITS z F ❑ Depth sta. Number I SUMPS J t ❑ Distance to nearest: Wal] FOlpfdatkm Property Line i DISPOSAL PONDS ❑ 1 -"'Y I hereby certify that I have prepared this application and that the work WIN be done in accordance vitt San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 3-+^^+J' f - I -. Home owner or licensed agents signature certifies the,10111wMN:"I coWthat 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 cornj*nsation lave 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, 1 shall employ parsons subject to workman's compensa- tion lawn of Califorri {t_ I /" -. The applica call for all required ilitspections. Compl ' drawing on reverse side. - t Signed / Title: .6 A,1 Cl Data: FOR DEPARTMENT USE ONLY Application Accepted by : Date - Pit or Grout Inspection byqq J f AAV f�Daft tV Flnaalls�Inspection by Data Additional Comnsnts: tip aJ "/i AV fr��/lt.j tjAr ' IAV'f i ❑ Stk 1666781 '❑ Lodi 3963821 -❑Minteoa 823-7104 ❑ Tracy 836-61Bb - ..• _ r Applicant - Return all copies to: EmArenmerdel Health Permit/Servipas 1601 E. Hazelton Ave.. P.O. Box 2008. Stk., CA BUM f. e ` FEE AatOUNT WE •AaW1MT RFMrnW CK RECEIVE0.BY - DAT ' i'Fo Was .dye CASH �r E 'EDI - . € . Bn 13-N IREV.1a,®1 - B$°O • I;Lq s y-O�, .�, 1161 1s 17,5