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APPLICATION FO I PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA REG Telephone 12091 6-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Tri licate) V�R�NM�N�A��! HfAL�H Application is hereby made to the San Joaquin Local Health District for a permit t construct and/or install the wor el �� b%,)41 p%%cation is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No 1862 for well/pump and the Rules and R ulations of the San Joaquin Local Health District. n / Job Address �� G��/ C� �- r T,� //G� /� /00 Q 3C�Co City Lot Size PM ` / 14ss 4�/cf � Owner's Name 10ve�JU/``� S�1O6gddress . a" —505/1:j �V 10, 971f, i Phone S��' Contractor ' Gt�A 7;k-_ cn ess /�.3Z�.�/ Lir nse No. -W-7z, ��d Phone TYPE OF WELL/PUMP: NEW Wal'OK WELL REPLAC MENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER bC 0WV-11i -AV DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU TION SPECIFICATIONS I ❑ Industrial El Open Bottom ❑ Manteca Dia. of We I Excavation 7�._ Dia. of Well Casing z H &i_4 Domestic/Private ❑ Gravel Pack / R Tracy Type of Ca ing Zye " Specifications f-1 Public 0thereWtA %1cR+fY F1 Delta Depth of G out Seal s z fzZ # r / p Typ of out�.._ I I Irrigation -Approx. Depth I 1 Eastern Surface Set Installed by A. Repair Work Done ❑ Typeof Pump H.P. State Work Done_ Well Destruction D. Well Diameter Sealing Material (top ') Depth Filter Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIR/ADDITION l 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation wil! e:' Residence Commercial 0 er - iE I Number of IN, g units: Number of b oms f i Character soil to a depth of 3 feet: Water table depth SEPTIC T K ❑ Typ fg Cap No. Compartments PKG. T ATMENT PLT. ❑ Method of a Distance to arest: Well �Foundation Propert e If LEA HING E ❑ No. ength of lines �81ngth/sizeFILTER BED ❑ Dt lance topare Well undati nProperty Line I SEEPAGE PITS I I Dept Size Number SUMPS ❑ Distance to nearest: Well Foundati n Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of the San Joaquin Local Health District. 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 workman's compensati n laws of California."Contractor's hiring or sub-contracting signature . certifies the following: "t certify that in theperformance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for II required inspections. Complete drawing on reverse Signed X // w Title: � ' `,�� /S . Date: �yfif�fl�� /✓/P/k'/f�lr FOR DEPARTMENT.USE ONLY Application Accepted by bate Area Pit or Grout Inspection byADUEA\NNT ate Fina Inspection Date Additional Comments: ❑ Silk 466-6781 ❑ Lantec 7104 4-racy 835-6385 i Applicant - Return all copies m /Se s 1 Ha elton Ave., P.D. Box 2009, Silk., CA 95201 FEE I INFO AMREMI CASH CK 4 RECEFVED BY DATE PERMIYNO. .. I ; + EH 13-24 1REV,I/n 51 EH 14-26 ...