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APPLICATION FOR PERMIT , ' SAN JOAQUIN LOCAL HEALTH DISTRICT " w ` 1601 E. HAZELTON AVE., STOCKTON. CA ,i - Telepho,e (209) 486-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , - 3K iComplete in Triplicate) IF Application F8 hereby made to the San Joaquin Local Health District for a permit to construct and/or IrMall the work herein described.This apf4lC91iOn Is •; "°# made in compliance witn Sen.Joaquin County Ordinance No.549 for sewage of No.1982 for well/pump and the Rules and Regulations of the San Joaquin ocat Health District. Job Address €tv�y//�)f'A r�q'Lot Size t ' PM i Address . C /':.F t Owner's Name �� Phone y!4r 1r C Contractor's Name/ /r/'/',('/!I C'�. f _ License No. - . p TYPE OF WFLLIPUM^ NEW WELL d WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION ❑ SYSTEM REPAIR a OTHER ❑ DISTANCE TO NF^AREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNrATION AGRICULTURE WELL OTHER WELL PITSISUMPS .; Rfi ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS zn-Ir� industrial C Open Bottom G Manteca Dia. of Wall Excavation Dia.of won Casing Specifications C Domestic/Private E Gravel Pack ❑Tracy Type of Casing— -- asi P 0 Public ❑ Other ❑ Delta Depth of Grout Seal Type Of Grout C.' Irrigation —,Approx. Depth ❑ Eastern Surface Seal Installed by State Work Done_ Repair Work Done ^ Type of Pump H.P. Well Destruction C We" Diameter Sealing Material!:op 50 6ixt;, Depth Filler Material(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION U DESTRUCTION u iNo septic system permitted if public sewer . available within 200 feet.) Installation will serve: Residence_ Commercial Other ~„ Number of living un€m: Number of bedrooms . ter table depth ,.i. . Character of aril to a depth of 3 feet:�........8-� -- Wa � �/ t' _ _ No. Compartments =� m SEPTIC TANK F�: typelMfg Capac�q'•-.♦.l - PKG.TREATMENT YLT.1:1Method of Dispgeal Distance to rme test: Weil Foundation Prope,ty,Line ; I EACHING LINE IY No. 3 Length of lines - Total lengthlaiN FILTER BED C Distance to nearest: Well /9 _ Foundation ,2 . PrOPWY,Line .2 47 Number SEEPAGE PITS ❑ DepTh Site ' SUMPS ❑ Distance to"nearest: Wall Foundation Property Line ' DISPOSAL PONDS G I hereby f ertlfy that I have prepared this application and i at the work will be done in.accordance with San Joaquin County ordinal as,Stele taws,and 3 rules arid regulations of the San Joaquin Local Health District. Horne owner or licensed sgenl•s signature certifies the following:"I certify that in the performance of the work for which this pemtit is issued.I shalt not employ any person In such manner as to become subject to workmen's compensatk,n laws of Celifarnla."Contractors hiring or sub-contracting signature certifies the following:"1 CwWy that in the performance of the work for whleh this pwrlt is issued.1 shad employ persons subject to workman's cornpensa- h tion laws of Callfom.a. " f8 The applleentItiW call for 0 required inspections.Complete drawing on reverse.side. Signed ` ��..L 'r Title: �_` Oars: - ;„. . FOR DEPARTMENT USE ONLY 4 .. _P i Application Accepted by mak=-✓ _ Rata - Area ` Final Inspection by D 7 ' Pit or Grout Inspection byof _..._ u... . Additional Comments: 6-E c' f _•`' ❑ Stk 468-8791 ❑ Lodi 369-3621 0 Mantes -7104 ❑Tracy Applicant-Return all copies to: Environrnental Health Permit?Services 19D1 E. hazehon Ave.;P.O. Box 2009, Stk.,CA 910M AMOUNT DUE AMOUNT REMITTED CASH RECENFD BY DATE PERMtrNO. �. FEE INFO - r�,,,�.t*tr t4m 4S Cth u� . 3-fi-�y FIt-MI �.Y_5�-'i'i'i ._.'..�L:YSi'�ts�i'.'-'�.��,.�n. '� �".�.3:? .—.-_- ... -r.. _.- -...—.�-r-..�rr-r..-►..1-"J.-.+..-+r.- ..._.a.++-.-•s-=-.-.rte.�---�.��mw.,...-.-� .