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APPLICATION FOR PERMIT ' .ill;/;; "USAN J04QU1N LOCAL HEALTH DIS 7CT 1601 E:?HAZ,ELTON AVE., STOCKTON, CA 11, Telephone (209) 466-6781 PERMIT fXPI!R,ES 1 YEAR FROM DATE ISSUED , (Complete in 'Triplicate) Application is heieby 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 Joaquiri County Ordinance N&I549'jtor sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 5 f It k R �'Y ;!4 City _5 _I.cTb� Lot Size PM 'Job Address , . �1. , P o. BOX 1137 . s-rackro►� ..�,A _ Phone yb6- zoZ . Owner's Name CA ss Addre OR I Contractor SPE E MT AJ Address,:IZ8Z.g BAST Mti27x E S'r License No.CS9 S1 ZZ68 Phone k TYPE OF WELL/PUMP: NEW WELL ❑f:}fir r ll` WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ ltl rRR YSTEM REPAIR ❑ OTHER X3MOfvl�&jA2G wF DISTANCE TO NEAREST: SEPTIC TANK a ,S91LINES DISPOSAL FLb. PROP. LINE r FOUNDATION ' j�'AGIRICULTURE WELL OTHER WELL�?0 fil PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM1A9EA CONSTRUCTION SPECIFICATIONS ❑ Industrial �' ❑ Open Bottom ❑ Manteca?(! Dia. of Well Excavation_ 1t_..r�t� Dia. of Well Casing 2 w y „ ,t,. ,; ik(.� I ;❑ Domestic/Private b(Gravel PaclgXAA►A)❑ Tracy "I s, Type of Casing F'✓o— Specifications 0 i f'l Public + n~ Other ❑ Delta ! '. Depth of Grout Seal ;7413 FT._ Type of Grout CIIryBVT/1A alD�l I I Irrigation ' ,- r �?.-Approx. Oepth l 1 Easternkl Surface Seal Installed by k1A7E5f! -d Repair Work Done LJ Type of Pump 1 H!P State Work Done_ �- _ 'h_ Well Destruction `❑ Well Diameter Sealing Materia! (top 501 -t - Depth ;is*,Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION,[1 REPAIRlADDITION I I DESTRUCTION I I fNo septic system permitted if public sewer is ?�'W available within 200 feet.)oil 1 j Installation will serve: Residence_ Commercial 1�1'Qther j j Number of living units: Number.af bedrooms, 4 Character of soil to a depth of 3 feet: Ij isl1�; Water table depth s}?d SEPTIC TANK El _Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ r. # Method of Disposal V 1 Distance to nearest 1Nell I Foundation' Property Line (� ;: 1 , LEACHING LINE .: 0 'No. & Length of lines Total length/size j it FILTER BED �" " `❑ Distance to nearest f'Well4r'R Foundation Property Line t SEEPAGE PITS r I I Depth Size`li '' Number i SUMPS ❑'' Distance to nearest:" d;We11)4E, Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application ad 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;D&rici.l1 Home owner or licensed agent's signature certifies the'`lollowiri& "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in 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�thovork for which this permit is issued,I shall employ persons subject to workman's compensa- M. tion laws of California."' �- a - i t #I i `The applicant must call for all required inspections Completeldrawing on reverse side. i kr ` Signed X �Qt� a '� ! Title: Date: w I LI9D , i. FOR DEPARTMENT USE ONLY Application Accepted by Date Area 1 Pito rout Inspection by Date! '� Fina! Inspection by Date ( Additional Comments: _;! ??IL3 �'i 9-5 _ ---- -- w❑ Stk 466-6781» , -❑ Lodi 369-3621' 4 ❑ Manteca�;823-7104 ;-❑ Tracy' 835-6385 -' ::Applicant- Return all copies to: Environmental Health Permrt/Services 1601 E.Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK 0 l , ;" =9fIIRLf FEE 'AMOUNT DUE AMOUNT REMITTiED RECEIVED By - DATE 1 ERMIT'NO. I INFO C SH +.E,{1]41IREV.tix5l ' II+ I, -26 EH 14 n D^� J