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* APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' t✓I W F 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 , PERMIT EXPIRES 1-YEAR FROM DATE ISSUED {Complete in Triplicate) Application is hereby 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 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address aS I'l l Q f1 WCL V "4`^f_d� Cit 0 /1 Z f f Y Lot Size O V PM ��// Pry• Bnx r 9+� //��/ �f Owner's Name } 1 0 �i ✓{ Address 900 SD T*, ;C,,oKee X06 r c.A Phone f Ao4 6 '^� 3 T � Contractor .� Q �.hC Address la e�,PtS�( 7, License No. b 3Z Phone0(.S SID TYPE OF WELL/PUMP: NEW WELL ® _ WELL REPLACEMENT ❑ DESTRUCTION A T a I PUMP INSTALLATION❑ SYSTEM REPAIR ❑ OTHER m �� r rr rC DISTANCE TO NEAREST: SEPTIC TANK Jqr- SEWER LINES 25a� DISPOSAL FLD. PROP. LINE m FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation �� Dia. of Well Casing '7 r14 ❑ Domestic/Private !'Gravel Pack ❑ Tracy Type of Casing -5c D v c- Specifications (1 Public f7 Other 71 Delta Depth of Grout Seal "ti S R L' I Type of Grout�P1�' P+1 17 I i lrri� tion Sb lApprox. Depth l 1 Eastern Surface Seal Installed b g A M 0✓+.I srr 4 _ W v Repan orkone ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 50') TYPE OF PT1C WORK: NEW INSTALLATION 17 REPAIR/ADDITION I I DESTRUCTION I I (No se system permitted if public sewer is ' Installation wi serve: Residence— Commercial— Other av le within 200 feet.) Number of living nits: - Number of bedrooms Character of soil to depth of 3 feet: + Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments , PKG. TREATMENT PLT. ❑ _ Method of Disposal Dis ce to nearest: Well Foundation Property.Line LEACHING LINE ❑ No..& Long of lin Total length/size FILTER BED ❑ Distance to ne WelI ! Foundation Property Line SEEPAGE PITS I 1 DeSize Number SUMPS D istance to nearest: Well ion Property Line DISPOSAL PONDS I hereby certify that t have prepared this application and 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 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 compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this per }1t is issued,I shall employ persons subject to workman's compensa- tion laws of California." cc��} The applicant must call for ail squired inspections. Complete drawing• Gude, Signed X `t t �xaylnln t� �y�C, Tit f QL� �(0(tF1 lSd' Date: F t fNT, QJ L it FOR DEPARTMENT USE ONLY Application Accepted by {��x-x�_ 1 7. L( Date r 7 Pit or Grout Inspection by Date Final Inspection by Date G Z J Additional Comments: ` '.rc 11 ilL ,,15LA I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835$385 Applicant - Return all copies to:.Environmental Health �7Permit/Services 160/1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I .+I..K_1„J r�.. yt�J1 L 1 {/��V✓S 1M. VOr�OQ- (� [� e 6 V FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED B DATE PERMIT'NO. t +. E"'13-24(REV.1 i H 5) ^��^ /`^ •,J f} p EH 11-28 D" v !—1/ SO