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-- r '1 tall, APPLICATION FOR PERMIT 1 � SAN JOAQUIN LOCAL HEALTH DISTRIL r 1601 E . HAZELTON AVE „ STOCKTON , CA TelephorSe ( 209 ) 466- 6781 PERMIT EXPIRES 1 YEAR FROM DATE_ ISSUED ( Complete in Triplicate ) Application is haleby 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 fur sewage or No , 1862 for well / pump and the Rules and Regulations of the San Joaquin Local Health District , AI 'N all - S/ D � I01 Crra i l� n � 12r� • PM Job Address II I�J! t!�iLC � rG� 1 T'. 0 -) City�1 1 L Siz Ct.ore6 Owner ' s Name rGiCt �(if< l_ Ua cL5 l � C Address ?� 3 14" L3 ? 10. 115 A ` - • . Phone co l P � tartco tJ CA — Contractor rPC fvd ) ) O1 � Ie5tr � AddreSs A ✓►twig lbldoi5 is License No . C., 414Y LL : Phone (415) tSb 444 TYPE OF WELL / PUMP : NEW WELL Q WELL REPLACEMENT U DESTRUCTION L) �x " PUMP INSTALLATION r ] SYSTEM REPAIR [I OTHER 0 5or � L� YIn/_t5 DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD , PROP , LINE J J FOUNDATION AGRICULTURE WELL _ OTHER WELL ____ PITS / SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f Sort "Bo rt1Ptc�5 O Industrial ❑ Open Bottom l.J Manteca Dia , of Well Excavation Dia . of Well Casing JJ 11 Domestic / Private 0 Gravel Pack Il Tracy Type of Casing Specifications 161 Public 11 Other I 1 Delta Depth of Grout Seal Type of Grout _ I 1 IrrlOation ,,__• Approx , Depth I I Eastern Surface Soul Installed by _ Repair Work Done U Type of Pump „ _ H . P . ._., , ,,, State Work Done ._ Wall Destruction 0 Well Diameter Sealing Material stop 508 ) Depth Filler Material ( Below 501 TYPE OF SEPTIC WORK : NEW INSTALLATION I 1 IMPAIR / ADDITION I I DESTRUCTION I I ( No soptic system permitted if public sower is Installation will serve ; Resavailable within 200 feet . )idence _ Commercial Other Number of living units : Number of bedrooms _ I Character of soil to o depth o1 3 feet : Water table depth _ SEPTIC TANK C"1 Type / Mfg .. Capocily No , Compartments PKG . TREATMENT PLT , 0 Method of Disposal Distance to nearest : Well Foundation .� Property Line ob� LEACHING LINE 71 No . & Length of lines �. • . Total length / size FILTER BED U Distance to nearest : Well _ .. Foundation Property Line SEEPAGE PITS I I Depth _ , Size _ Number _ 01A SUMPS L ) Distance to nearest : Well _ . Fourldatinn Property Lina DISPOSAL PONDS ❑ 1 hereby certify that I hove prepared this application and that the work will Ile done in accordance with San Joaquin county ordinances, state lows, and rules and regulations of the San Joaquin Local Health Oi§ trint . Home owner or 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 employ any person in such manner as to become subject to wurkman 's compensation laws of California , " Contractor' s hiring or subcontracting signature certifies the following : "1 certify that in the performance of the work for which this permit is issued, I Shap employ persons subject to workman's compansa- tion laws of California , " The applicant must call for II required inspections . Complete drawing on reverse side, Signed Xr Date : RR 0 P9RTMENT USE ONLY Application Accepted by — � �— = ice % Datere C Pit or Grout Inspection by Date Final Inspection by � Date Additional Comments : d � � ZU — d�� /CC �� 0 Stk 486-8781 ❑ Lodi 3fi9-3621 0 Manteca 823.7104 ❑ Tracy 835. 8385 Applicant • Return all copies to : Environmental Health Permit / Services 1601 E. Hazelton Ave . , P , O , Box 2009, Stk . , CA 95201 INFO AMOUNT DUE AMOUNT haMITTED AS RECEIVEDf1V bA7E PERMI7 ' NO . • EH 13•24 ( REV, V M ) I ' O FH 14.20 •�s ��I � I