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s . : ob fA APPLICATION FOR PERMIT / SAN JOAQUIN LOCAL HEALTH DISTRICT �. ' 1601 E. HAZE T ON AV�., STOCKTON, CA Telephone (209L4&&-61fFf-- Z/-/ 1a , PERMIT EXPIRES '"YEAR FROM DATE ISSUED (Complete in Triplicate) E 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 � ity Al�`'" Lot Size [� PM /7C._v[.�G tt ee 11 ° r.15 Owner's Name �aR f� " Address -�[/ / '/� tf Phone Contractor Ml s wntnm Address-Qjl License No. `� Phone TYPE OF WELL/PUMP: NEW WELL)q WELL REPLACEMENT ❑ DESTRUCTION ,e7 PUMP INSTALLATION SYSTEM REPAIR ER ❑ FLI DISTANCE TO NEAREST: SEPTIC TANK 'F- SEWER LINES _ � DISPOSAL DPROP. LINE FOUNDATION ir�� I AGRICULTURE WELL -30� OTHER WELL PITS/SUMPS �e' -f- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia. of�-Well- �eavati y' Dia,-o#�ldlel!-using �Domesoc/Private ravel Pack ❑ Tracy �NType'of Casing 1t� Specifications ��' L 1� �. S' E 1 Pubfic n Other ❑ Delta 134ih-of Grout Seal Type of-Grout-i! 4� �.f%cp vii w.- t I Irrigation .G�Approx. Depth I I Eastern S rface-Seal'lntalled by-i'==_ Repair Work Done ❑ Type of Pump H.P.•t% ^, lb State Work DoroeJAS Well Destruction ❑ WellDiameter .-,�.��_�---dealing Material {top:- i t Depth_ R —f,Filler'Matetial (Bel 5� D � �'� TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRYADDITION ji DE=ST UCTt N•1,#oiNo.seb-c4ystem permitted it!public sewer is t;'N` I > a+iailable within 200tfeet.l Installation will serve: Residence_ Commercial_ Othler: Number of living units: Number of bedrooms `'� 4-�---'1 Character of soil to a depth of 3 feet: __ Water table depth f SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments s PKG. TREATMENT PLT. ❑ Method,of Disposal �'J Distance to nearest: well Found tion ` Property._Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [ I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line �J DISPOSAL PONDS ❑ 1 hereby certify that I 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 Diltrict. 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 no ' employ any person in such manner as to become subject to workman's compensation laws of California Contractors hiring or sub-contracting signature i certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa-,.-_ tion laws of Calif nia." The applica must o re .'ns ctions. Complete drawing on r rsa side. Signed X Title: D te: 74 FOR DEPARTMENT USE ONLY s Application Accepted y Date C7 Z Area Pit or Grout Inspection by Dat - "r Z Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 D anteca 823"71404 ❑ T cy Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2899, Stk., CA 95201 &,V4q4 r.,?kw U^e// JZ)of ss 9/s FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED E3Y DATE PERMIT NO. INFO CASH O. +.EH 13-24 MEV.1 i N 5) 1 r�' 1 1 AXI SF�,[_ e�� EH 1428 vV �J