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APPLICATION FOR PERMIT Ar W-0 : SAN JOAQUIN LOCAL HEALTH DISTRICT r I. 1601 E. HAZELTON AVE.,.STOCKTON, CA t —Tele1phone {209) 466-6781 ,.s > . �,r1 tZ ,P-3 4.k e;! I� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �] 4 `(Complete in Triplicate). '; : v. - Y t /✓cP�J -�'�+�-C �J�,} 'Yi�� " �, 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 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 HealtL�Z Job AddresCity Lot Size � 160PM1M1Owner's NaAddress PhoneE- `s Contractor `'resss / _ _ License No �D Phone'TYPE OF WELL/PU.MP;z [I: NEW WELL E3 WELL REPLACEMENT ❑ µDESTRUCTION ❑ PUMP INSTALLATION!❑ SYSTEM REPAIR ❑ OTHER ❑Ir 1 DISTANCE TO NEAREST: SEPTIC fiTANK SEWER LIMES f' DISPOSAL FLD. PROP. LINE {FOUNDATIONS/{ AGRibOLT•URE WELL- �i'' OTHER.WELL PITS/SUMPSt— INTENDED USES` '-TYPE OF WELL: PROBLEM AREA CONSTRrUCTION SPECIFICATIONS f ❑'Industrial El Open Bottom ,,.LJ Manteca Dia. of Well Excavation _,Dia. of Well Casing is El Do ❑ Gravel Pack a❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout F ❑ Irrigation 24prox. Depth ' ❑ Eastern Surface'Seal Installed by i Repair Work Done ❑ Typerof Pump R H.P. ' # _ State Work Done Well Destruction j 1:14 Well Diameter Sealing Material (top 50'), ( Depth a `- Filler Material,(Below 50') I s TYPE OF SEPTIC WORK: NEW INSTALLAT,ON ❑ REPAIR/ADDITIO E RUCTION ❑,°'No septic system permitted if public sewer is ; 1 .x E vailab witFiin 200 feet.l Installation will serve: Residence— Commercial— tither" ' Number of living units: M Number of-bedraoms Character of soil to a depth of 3 feet: . Water table depth SEPTIC TANK ❑ Type/Mfg Capacity CNo!Compartments , I PKG. TREATMENT PLT. ❑ '. T Method of Disposal E Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size F a FILTER BED i ❑ Distance to nearest: Well foundation `Property Line p . ...i` "" Number SEEPAGE PITS ❑ De th Y.'•'."."'.`�._Sze � 3 SUM ❑ Distance to nearest:.. Well Foundation Pro PS perty Line DISPOSAL PONDS ❑ � ..-----f hereby certify that I have pJepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sari Joaquin.Locaf Health District. ` Home owner or licensed agent's signature certifies the foll6wing:. I certify that in the performance of the work for which this permit is issued, I shall not employ any person'iin such manner as to become subject to workman's compensation laws 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, I shall employ persons subject to work�an's compensa- tion laws of Califonhpia." _ The applica ustgcall for quired ins ctions=Complete drawing on reverse side. Signed Title: 4yel tFOR DEPARTMENT USE ONLY Qr � { Application Accept d bDate _ FI Pit or Grout InspectionDate Final Inspection by Date.�L Additional Comments: _ ❑ Stk 466-6781 antec -7104 ❑ Tracy 835 6385 Applicant - Return all ental ealth P mit/ rvic 160 H Itone., P. Box2009, Stk., a FEE : AMOUNT DUE' TTED CASt� RECEIVED BY DATE PERMI7'No. INFO + EH 13-244REV.1iH51 EH 14-26 .J f ffl