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1 APPLICATION FOR PERMIT j SAN JOAQUIN`L_OCAL HEALTH DISTRICT 1601 E. HAZES T ON AVE., STOCKTON, CA Telephone 66- (2091 4fi781 I PERMIT EXPIRES 1-YEAR-FROM DATE ISSUED1 r (Complete-in-Triplicate)'r. 47 F .;c— ;^:is �_ ' '..'1#1•`�S '-',,,. .' ;35- - )f...+�: :.♦s:' F .... ..�. ,• to t and/or all the work herein cation is Application is hereby made to the Joaquin County Ordinance Health District for sewage or it 1862 forhel//pump atnd the Ryles and flegu ations of he Sant Joaquin made in compliance with S q ,. ECu,� Local Health District. r T �7/.� �-`� G S ' �D' t x= •. ,.n: :.,City �7it=.t/ Lot Size QAC PM <r. Job Address 4 = ,tiv, r�.• .' �.. >. Owner's Name"_'L��-�L� Address= Contractor_F�yA� Address , kJL�✓ License No.�1'-�� Phone �iS'397/ I- TYPE OF WELL/PUMP: NEW WELL ElWELD REPLACEMENT (-1 DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 11 DISPOSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial a ❑ Open Bottom ❑ Manteca Dia.of Well Excavation .! r =a:5-'• +J'N J` c r�Type-of Casing Specifications •.29,Domestic/Private 4X-3-Gravel-Pack- `� 0 Tracy--^ f. ❑.Public ❑ Other # El Delta Depth of Grout Seal Type of Grout ❑ Irrigation J4pprox. Depth ❑ Eastern�� Surface Seal Installed by H P. State Work,Done Repair Work Done ❑ Type of Pump a4 .F - J Well Destruction ❑ Well Diameter'- Sealing Material Itop 50') Depth Filler Material (Below 50'1 1 TYPE OF SEPTIC WORK:- NEW INSTALLATION ❑ REPAIR/ADDITION DESTRU/ION ❑ aviailablelwithin e200 feet.) if public sewer is l ?�{ r installation will e: Residence� Commercial_ Other Number of living units: Number of bedrooms _ r` Character of soil to a depth of 3 feet: _ Water-table depth t SEPTIC TANK ❑ .Type/Mfg Capacity No. Compartments i57Method of Disposal PKG. TREATMENT PLT. ❑ = 'r , Distance to nearest; Well Foundation Property Line / � � ,Total length/size LEACHING LINE No. & Length of lines l �, FILTER BED ❑ ,Distance to nearest: Well_/e9e1' Foundation 4- - Properh+-Line $[7D SEEPA6E-PITS CAS Depth LSize Number i SUMPS ,�,. 0. Distance_to-nearest: Well Foundation _ p� Property Lined J DISPOSAL PONDS ❑ I hereby certlfy that I have prepared this application and that the work will bed"ane in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner br licensed agent's signature certifies the following: "I certify that in-the performance of the work:for which this permit is issued, I shall not eploy any person in such manner as to become subject to workman's compensation laws of California Contractor's hiring or sub-contracting signature cemrtifies the following:-I certify that in the performance of the work for which this permit i, tissued,I shall employ persons subject to workman's compensa- I `tion laws of California." The applicant must call for-all-required inspections, Complete drawing on reverse side. k `v l _ Title:y` ® !, Date: l Signed'�C � !,[hn , �+ t F R DEPARTMENT USE ONLY - Date Area 4A plication Accepted by r _ Date. 'Date =-r Final Inspection by Grout Inspection by , i 'Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑'Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 r CK FEE AMOUNT- t)UE - AMOUNT: REMITTED_—CASH— :67 `rRECE1VED,BY,w,,� ._ DATE, �r IN I + EH 1324(REV. 1 /e5)L EH14-26 `' .r »_r_, .......--_.....�-.,«.y,.,5-•.-F....w .._ .�. _