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APPLICATION FOR PERMIT ` oos �. .. � � SAN JOAQUIN LOCAL HEALTH DISTRICT , } 1601 E. HAZELTON AVE:, STOCKTON, CA "L y Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 9 for sewage or No. 1862 for well 1pump and the Rules and Regulations of the San Joaquin Application is hereby made to the San Joaquin Local Healtoh District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin county Ordinance , Local Health District. ,�� (� l�t,t2^ PM ��{ I� �_ ��`3 City ..9�f , Lot Size f� Job Address 4 39.Z-7 ��ad essf` �fes] S� Phony _ Owner's Name 2 �� - ' t�l`� License No.��J?"-�—Phone a Address 9 L2 Contractor 's ` WELL REPLACEMENT ❑ DESTRUCTION ❑ ' NEW WELL OTHER ❑ r TYPE OF WELL/PUMP: ,� SYSTEM REPAIR ❑ PUMP INSTALLATION r DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES ��-- PITS/SUMPS "+ ' _�AGRICUi,TURE`WELL OTHER WELL f . _'- t FOUNDATION �� j •y INTENDED USE TYPE OF WELL PROBLEM� AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing I f Open Bottom ❑ Manteca Dia. of Well Excavation 1 i, ❑ Industrial Type of Casing . Specifications �y ; ❑ Tracy Typ ai Grout 1 D Domestic/Private Q Gravel Pack Depth of Grout.Seal ..n Delta _ •� -i � hh Ll Other -r _ W,7 Fl.Pu`blic" t— A. lel astern--�-- aaceSe.LW "�s,Irrigation Approx. Depth. h7 State Work Done _ i - .t Repair Work Done ❑ Type of Pump Sealing Sealing Material (top `50') , ' Well Destruction ❑ Well Diameter �— r Depth* Filler Material IBelow 50'! wer i k I, available within 200 feet.} TYPE OF SEPTIC WORK: NEW INSTALLATkON {.l RI=PAIRIADDITION 1 I DESTRUCTION l 1 lNo septic system permitted if p�u�i � Installation will serve: Residence I Commercial Other [[[ Number of Vining units: Number of bedrooms Water table depth =+ �' r -Character of soil to a depth of 3 feet: Capacity� No. Compartments SEPTIC TANK ❑ Type/Mfg {Method of Disposal PKG. TREATMENT PLT. C7 Foundation Property.Line Distance tp nearest: Well ' ' Total length/size LEACHING LINE w ❑ No. & Length of lines Property tine Foundation ' FILTER BED ❑ Distance to nearest: Well �s t Size Number SEEPAGE PITS . 1 1 Depth Property Line ' SUMPS Ll Distance to nearest: Well Foundation I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state I and DISPOSAL PONDS ❑ rules and regulations of the San Joaquin Local Health District. Home owner l licensed agent's signature certifies the following: "t certify that in the performance of the work for which this permit is issued, I ign manner as to became subject to workman's compensation laws of California "shall employ persons{subjecC ngri rt tow, orkman'scompensa employ any person in such man w certifies the following: "I certify that in the performance of the work for which this permit is �x tion laws of California." t The applicant call to all required inspe ions. Complete drawing on reverse side. �h ,�„�_•-- (/� 4 N �I ©Z .' Date: Tide: Signed X F �EN_T USE ONLY F � 4 AAA • r Date Area ff Date_ Applica' ccepted by r A. _� jd-1-- e Date �._`. � "'S Final lnspe_ctibn Pit of pGr.)nspelction by,` 47) !U u Z.4r S [I. . Additional Comments: -.;.Q-Manteca• 823-7144 Tracy 835 6385." U Q-Stk_466-6781..-._:., Q.Lodi 369-3621. .-. Stk., CA 95201 Applicant - Return all copies to: Environmental Health Permiti i Ave., :0• Box 7 i`�`�/eI�a U 4� �aeAv —y`"'��.��-� PERMIT NO.; + CK RECEIVED BY DATE FEE AMOUNT DUE AMOUNT REMITTED CASH INFO SIL�3 f y ° G�`' ��?��✓�- a +.EH13-24[RE1l.t/H51 EH 14-28