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.. a'•�'(......., 5-7-�:^. -,•r.r ..._.T!'�5;.:'�:=1... .a... �.u'�ra'..a.:'-ie.'aar',-.:AS+.� - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) the sAn n Ordinance flo.549 for sowa,/e or No. 1862 for well/Pump and the Rules and Regulations n1 the San Joaquin Application is hereby mh SanoJoaquin Joaqu n CoutyLocal Health District for a permit to construct and/or install the work herein described.This applade ication 1s made in compliance w n� Leal Health District. PM � G� lot Size • n ^ City P Job Address �� a / �- Phone -��v Address owner's Name � rl-7pb /yam Mme_License No.5 Phone n /1_ GL Address DESTRUCTION ❑ Contractor—, -L- WELL REPLACEMENT L!NEW'WELL ❑ OTHER [3TYPE OF WELL!PUMF: STEM REPAIR C1PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE SYSTEM SEWER LINES — pITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL FOUNDATION t PROBLEM AREA CONSTRUCTION SPECIFICATIONS i INTENDED USE TYPE OF WELL _ Dia.of Well Casing ❑ Open Bottom ❑ Manteca Dia. of Well Excavation�-- gpecifications { ❑ Industrial Type of Casing ❑ Gravel Pack I]Tracy Type of Grout ! U Domestic/Private 1-1 Delta Depth of Grout Seal _ i f-1 Public Cl Other { Approx. Depth I I Eastern Surlace Seal Installed by I I Irrigation H P Sealiny Material(top 50'1 State Work Done__ Repair Work Done L3 Type of Pump �— I Well Destruction ❑ Well Diameter ---- Filler Material(Below 50'1 Depth N 1 available within 200 feet•I r TYPE OF SEPTIC WORK: NEW IN,T;.'.LATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is 1 Installation will serve: Residence L/Commercial Other /1 Number of bedrooms _ —_Water table depth Number of living units: — rooms i No. Compartments t Character of soil to a depth o}3 feet: CapacitY� i SEPTIC TANK ❑ Type/Mfg 7 Method of Disposal } T PKG.TREATMENT PLT.❑ Foundation Property Line Well ��- t Distance to nearest: WelFT �/� 'C'7' �T�ot7a�l'length/size LEACHING LINE No. &Length of lines OFT Foundation s� Property Line FILTER BED ❑ Distance to nearest: Wali�— / - 7 L/ �— Number Sire �T fT SEEPAGE PITS I I Depth �— Property Line SUMPS Distance to nearest: Well — Foundation DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will bo done in accordance with San Joaquin county ordinances,state laws, and rules and regulations of the San Joaquin Local Health 03trict.g subject to workman's compens?tion laws o4 California."Cotracto�snsir Fact o worktman!scompansa- Home owner or licensed agent's signature cart;ties the following: I certify that in the laws of anee of the work for which thior s petnlit o issued,I signature shall not t employ any person in such manner as to become certifies the following:•'I certify that in the parformancn of the work for which this porm t is issued.I shall employ Pe tion taws of California." qc. The applicant must call for all requir d inspections. Complete drawing on reverse sid/ Date: Title:Vis/ Signed X FOR DpOARTMENT USE ONLY Date •" Application Accepted by , V� / / _ Date Date. Final Inspection by Pit or Grout Inspection by ------- — e Additional Comments: ❑ Manteca 823-7104 ❑Tracy 835-6385 ; C Stk 466.6781 ❑ Lod' -W-3621 P.O. Box 2009,Stk., CA 95201 1 t Applicant- Return all copies to: Environmental Health PerrnitlServices 1601 E. Hazelton Ave., CK CpERMIT'NO. i AMOUNT hEMITTEO CASH RECEIVED BY _ -DATE_ _ + FEE AMOUNT DUE INFO ^7 1 C ..EH 1124 1REV.illtS) - EH 142E