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APPLICATION FOR,PERMIT SAN JOAOUIN'LOCAL HEALTH DISTRICT 1601 E. HAZE 1 ON AVE., STOCKTON, CA r Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �x � 4 ,d .(Complete in Triplicate? - lroation is 3...e f for sewage or-No. 1862 for well/pump and the Rules and Regulations of theSanJoaquin made to the San Joaquin Local Health District for a permit to construct and/or install the work her described.Tliss app Application is hereby Joaquin County Ordinance No.549 I4 made in compliance with San .. r, x k .. Local Health District..,t , $ • i � ,� �-� PM � City ! � /��- Lot Size - E �_.��F � ��Y _ -63 6 =S�ira l Job Address Phone 63 /+7,��0 Address Owner's Name phone05 License No. --1ES —�DTRUCTION C1Contractor's Name WELL REPLACEMENT ❑ = NEW WELL ❑ 1 OTHER 13TYPE OF WELLIPUMP: SYSTEM REPAIR ❑ PROP. LINE PUMP 1N574LLpT10N ❑ DISPOSAL'FLD.�-- SEWER LINES OTHER 1IUELL PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK �- AGRICULTURE WELL I — FOUNDATION 1— �. i TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS Dia.-of Well-Casing- WTENDED USE ❑ Manteca Dia. of Well Excavation Specifications j ❑ Open Bottom .L] Industrial ❑ Tracy Type of Casing Type of Grout 0 ❑ Domestic/Private L] Gravel Pack❑ Other ❑ Delta Depth of Grout Seal 4 f � ❑ Public ❑ Eastern Surface Seal Installed by _^Approx. Depth State-Work Done ❑ Irrigation H.P. j..� i Repair Work Done ❑ Type of Pump --� Sealing Material [top 50'1 Well Diameter r� k Well-Dest�ction Cl Filler Material (Below 50') Depth REPAIRIADDITION ❑ DESTRUCTIO�N'�(No setic sy within200emitted if public sewer as TYPE OF SEPTIC WORK: NEW 1NSTALLATION � R1 „ Commercial�Other lnstallationtwill serve: Residence Ve Water table depth Number,ofIliving units: Number of bedrooms 1- - 8 No. Compartments ' �"'C�1 acter of_soil to a depth of 3 feet: 2 S Capacity SEPTIC TANK' Type/Mfg Method of Disposal _ j Property Line L_� PKG. TREATMENT PLT.❑ 'Fou dation 1� Distance to nearest: Well r r 1 Total length/size L Property No. &Length of lines Perty Line LEACHWG LIME CDFoundation 1-- �— FILTER BED Distance to nearest: Well—� ( Number ❑ Depth Size Property Line - SEEPAGE PITS. �`� riFoundation�—^� D- Distance to nearest: Well SUMPS ~} i ty ordinances, state laws, and DISPOSAL PONDS ❑ _ that I have prepared this application and that the work will be done in accordance with San Joaquin coup I hereby certify that in the performance of the work far which this permit is issued, I shall not rules and regulations of the San Joaquin Local Health District. 1 certify signature Home owner or licensed agent's signature certifies the following: " compensation laws of California."Contracto�nsrsubject t workman�seompensa- employ any person in such manner to become subiect to workman's certifies the following: " l certify that in the performance of the work for which this permit is issued,l shall employ pe tion laws of California." ctions. Complete drawing on averse side. The applica call for all quire i Pe Date, d Title: Signed1 FOR DEPARTMENT USE ONLY O Z / Date Area �-� cation Accepted by Date Apph Final inspection by Date Pit or Grout Inspection by / f Additional Comments: ❑ Lod jg-3621 ❑ Manteca 7104 ' 0 Tracy 835.6385 t ❑ Stk 466-6781 i Applicant- Return all capias to: Environmental Health permit/Services 1601 E.:Hazelton Ave., P.O. Box 2009. Stk.,,CA 952 pP - . � - DATE PERMIT'NO. RECEIVED BY AMOUNT REMITTED CA ' IFEE NFO AMOUNT DUE n._ c - -•--�. - �� -� +Eli 13-24 IREV.10/831 ° C, _.. EH 1428