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APPLICATION FOR PERMIT \ ` SAN JOAQUIN LOCAL HEALTH DISTRICT" 1601 E. HAZEL T ON AVE., STOCKTON, CA . Telephone (209) 466-6791 PERMIT EXPIRES TYEAR FROM DATE ISSUE !L E3 C 0 P Y (Complete in Triplicate) Application is hereby made to the San Joaquin Lacal Health District for a permit to construct and/or install the work hemid'described:TNsrapplicatlon 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. QAw7-4 LN1. Job Address �� / T6� City J%A^ A Lot Size /L 4� ' k4li PM Owner's Name Address Phrj'ns T Contractor Addtess 'r•6a a:e Nl°IEA License No. Phone t� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 0 \l1t PUMP INSTALLATI014 O SYSTEM REPAIR ❑ OTHER" ❑ Q DISTANCE TO NEAREST: SEPTI TANK -SEWER LINES - - DISPOSAL FLO. /,PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL====,,, PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION"SPECIFICATIONS ❑industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications M Public Cl Other - Ll Delta Depth of Grout Seal Type of Grout_ I I Irrigation ,Approx. Depth I I Eastern•, -§udace Seal Installed by Repair Work bond' '0', •Type-of Pump•-- H.P. State Work Done - - WeiGDestruction , E] Well Diameter Sealing Material Itop 50'1 i Depth 'Filler Material (Below 50') TYIbE OF SEPTIC'WORK: NEW INSTALLATION 11 REPAIR/ADDITION DESTRUCTION 1 I INo septic system permitted if public sewer is ./ available within 200 feet.) Installation will serve: Residence_ Commercial y. Other Number of living units:_ -Number of bedrooms Character of soil to a depth of 3-Last: I 1 SEPTIC TANK O Type/Mf }_r Water table depth 9 �W� Capacity No. Compartments PKG.%'fiEATMENT PLT.❑ ` Method of Disposal Distance to nearest: 4y"ll —Foundfation Property Line - e LEACHING LINE ❑ No. & Length of lines 6` 76tat length/azo FILTER BED. 'Distends to nearest: Well ¢ Foundation'Lb �'-Prerty Lina IQ 0.4 fC m 9 rT4 " /Ar jEe`Il+'K 50 SEEPAGE PITS I I Depth Size - Number - SUMPS ❑ Distance.to.nearest: - Well Foundation PrupartpLLine DISPOSAL PONDS O 1 hereby certify that I have prepared this applips2lion an5llat the work will be done in accordanbe_- RIt,Sa`n,,�daquin county ordinancesstate laws,and rules and regulations of the San Joaquin Local Hegj(h_bisirict. ,/ --_ ! : - Home owner or licensed agent's signature certifies th44ollowing: "I certify that in the performance of the work for which this permit is issue I s"rrot employ any person in such manner as to become sub7J�ct to workman's compensate ws of California."Contrrlctors hiring or wbcontraetigqgg signature tion laws of California certifies the following:.""I terrify that in the performen6e of the work for which this permit is issued,I shall employ persons subject to,workman'&bmpensa- .� , The applicant must call for all required inspectionk. Complete drawing'on reverse side. - Signed X =Z_Aox �, `"Title: C�-cn us.®+ - onto: ` 'ipJ�, F DEPARTMENT USE ONLY 1,�^ / Application Accepted by A Dae t `+ `` Area - ;.r PK or Grout Inspection by Data Final'Inspection by p « - Additional Comments: ❑ Stk 468$781 ❑ Lodi 369-3621 ❑ Maniacs -1123-7104 O Tracy 8358385' _t� Applicant - Return all copies to: Environmental Health Psrmit/Services 1601 E. Hazptton Ave., P.O. Box 2009, Stk., CA 95261 FEE AMOUNT DUE AMOUNT REMfTTED CK RECEIVED BY 1U` INFO CASH DATE PERMIT'NO. EN 142%IREV.I/x51 EN Nle