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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE'TON:AVE., STOCKTON, CA Telephone (209) 466-6781 , 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED s�I� rY.. y t'.3i 18 «��.t: °,• .,, ,'y, :. .. ...4. _ (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,coinpliance;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. Jab Address City5 �;Lot Size 2' /�+� PM 'rW Owner's Name Address a1` Phone � Q } s b a Contractor' s.Name-Ua"-'�--� �— - 'LicOnse No: Ph°rae TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 0 !. i PUMP INSTALLATION SYSTEM x SYSTEM REPAIR ❑ -OTHER ❑ _ a DISTANCE To NEAREST: SEPTIC TANK SEWER LINES i DISPOSAL FLD. / if —,57—a r l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED USE _TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavatio � i Dia. of Well Casing omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing t5pecifications i p Public ❑ Other ❑ Delta Depth of Grout Seal Typ f rout i Irrigation FA24ppr0x, Depth ❑ sterri: Surface Seal Installed by Repair Work Done ❑ : Type of Pump~b1H.P. ' ` State Work Do Well Destruction ❑ Well Diameter Sealing Material (top 50') ' 1 Depth U Filler Material (Below 501 TYPE O,�SEPTIC:WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Install'• n will serve: . Residence— Commercial— Other_ Number of:Ilivi Number of bedrooms 1 F =f F Watedtable depth Character'°f?sail.to a dept eat: SEPTIC TANK es:5- ± _.Type/Mf9 Capacity ry -No. Comartments PKfr:TREATM PLT. ❑ Method of Disposal �. Distance to nearest: Well Foundation Property Liner div LEACHING LINE '�'3 LO No. & Length of lines f _ tal length/size FILTER BED �/" ❑ Distance to nearest:- Well Foundation erty Line_ r SEEPAGE PITS ❑ I Depth Size Number SUMPS ❑ Distance to nearest: Well —'Foundation Pre arty Line 7'—'DISPOSAL PONDS"._:-0. p V R I hereby certify that I have repared this application and that the work-will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the,San Joaquin Local Health District. Home owner or licensed agent-'s-signatute-c6enifies-the following: "I certify that in the performance of the work for which this permit is issued, I shall not r employ any persona.in$uctr-manner as to'becofne subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:;�l.,cortify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's a mpensa- tion laws of California."f `tt{ The applicant must call J alltrequired inspections. C pl to drawing on reverse side. Ss Tf. - , fined '` Title: = Date: FOR DEPARTMENT USE ONLY 1 - ' ir a tJ 1(� � Date n Area Application Accepted by Pit or rou Inspection by Date Final Inspection by Date t a Ap ditional Comments: Y66-678El F' Stk 41'' Lodi 369-3621'~ : ❑ Manteca 823-7104 El Tracy Tracy 8355-6 i pplicant- Return sil copies to: Envirorimenial Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 — AMOUNT DUE_-! AMOUNT REMITTED • 'iCACKS "RECEIVED BY, —DATE . c. PERMIT,"NO. INFO + EH 13.24 1REV.10183} } X105 /�� -IN. . EH 14-26..-.. _ ..�.-�.