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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT O 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED mplete in Triplicate) Application 's ma a to the San Jos, �wi alth District for a permit to construct andlor install the work herein described. This appApplication is het Y e, ;uin CouOrdihance No.549 for seWage or No. 1862 for welllpump and the Rui nd Regulations of the San Joaqurn made in compiiance With San Joaqt ;T� Local Health District. jr,t)fT rt49'' y l PM r't, , City !v Lot Size Job Address 45 r f f rrf f}F�iv/ s �s. •. ' /. ». 1?,'L1 a 1T'Address Phone r .� r .'f / ,ter Owner's Name t ' + ' tYte "Y1 :++ s~ K�i tad dr- pr+ �pH 721` l. rr f !._f..,': -Phone Y ' dress License No.=��--- Contractor r f'r 1 DESTRUCTION ❑ NEW WELL ❑ WELL REPLACEMENT ❑ OTHER �y f =r j:w ? TYPE OF WELLIPUMP: SYSTEM REPAIR ❑ PUMP INSTALLATION O DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ��--� OTHER WELL 'PITSISUMPS _ FOUNDATION � I AGRICULTURE WELL _.. . .•—- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. oflwellCasingr 7, � f �..:. f [.7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications f�,.?e.��'sr r 3�' 1 ❑ Tracy Type of Casing [::1 Domestic/Private ❑ Gravel Pack Type of Grout - r k Cl Other Cl Delta Depth of Grout Seal ['I Public I Surface Seal installed by 4 I Irrigation _Approx. Depth I I Eastern State Work Done ` �' Type of Pump H.P. [ Repair Work Dohe ❑ z Sealing Material )top 501 Well Destruction ❑ Well Diameter �---- Depth • Filler Material (Below 50.1 available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION 1 l REPAIRlADDiTION I I DESTRUCTION I 1 ave septic system permitted if public sewer rs Installation will seive: Residence—t Commercial— Other_.. Number of,living units: Nurnl&of bedtooms Water table depth VO Character of soil to a depth of 3 fee0 Capacity- No. Compartments Ajl�l ,r SEPTIC TANK ❑ 'type/Mfg Method of Disposal PKG. TREATMENT PLT.G ~ Property Line Distance loiine&i�st: Wel Foundation P Y I, 7ota1 length/size , LEACHING LINE C1 No. $ Length of lines Foundation Property Line FILTER BED ❑ Distance to nearest: Well t f Size Number SEEPAGE PITS [ I Depth Property Line LT DistanebIto neatest- Well __.. >=oundation SUMPS Y DISPOSAL PONDS ❑ I hereby certify that I have preParBd this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health District. 11 work for Home owner or licensed as3m8nnegas'torbecoin�e subjecties ihO lto wo kman'sHcompensation lify ihat in the awsoof Califoronia-�Co tractor srhiring orr ub�ontractngthis Permit is issued, [signatushall �e employ any person In such certifies the following: "I certify that in he paHormance of the work for+which this permit is issued, I shall employ persons subject to workman s compens tion laws of California." The applicant must call for all required lnspedtions. Complete drawing on reverse side. _ F bate: Title: Signed X E . f FO DEPARTMENT USE ONLY ) (F Area Application Accepted by SSI Date I Pit or Grout Inspection by ` Date o, Final Inspection by C3 S "All l�e/ si�Gl� Additional Comments: Cd Tracy -6385 ❑ Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 Applicant- Return all copies to: Environmental Health Permit/Services 1641 E. Hazelton Ave., P.O. Box 2009, Stk.; GA 95201 L; CK RECEIVED ByDATEPERM11 N0. FEE AMOUNT DUE. AMOUNT REMITTED CASH INFO . EH 13.24(REV.I/e 5) rH 14-2e i