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r e� APPLICATION FOR PERMIT y. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PAYAftmr Telephone (209) 466-6781 FtZCLrJr/'L'rD PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP 26 �� (Complete in Tr--iplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install Awj, This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Ru d WORn Joaquin Local Health District. l �VECES M,Job Address C- City Lot Size f M Owner's Name ( F4'6 D PY"pf7Ltt2 C Address • mak Zs 4C OF 1��'ni`p Phone - S`r1 23 Contractor Address License No. Phon TYPE OF WELL/PUMP: I NEW WELL CK WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER>< C3� M •0.4fa DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDA'T'ION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT10t it 1�5 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing h If Domestic/Private ❑ Gravel Pack. ' C4 Tracy Type of Casing—A/C, id,•40 Specifications l`l PublicW Other F1 Delta Depth of Grout Sealy •� • T pe of Grout�4!!. ! I I Irrigation5.+r Approx. Depth E I Eastern Surface Seal installed by dc, .f a»Kri j Repair Work Done El Type of Pump A20^- H.P. State Work Done_ fI)d r,J� o- Well Destruction ❑ Well Diameter-� Sealing Material )top 50') -F tom- °° Depth �5 I Filler Material Melow 50') •Af .Sa ,t rct, tg &Ck TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION ! I (No septic system permitted if public sewer is Q available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 leer. Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ Method of Disposal ri Distance to nearest: Well Foundation Property-Line A LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED. ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth. Size Number I SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ J. 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 n rules and regulations of the San Joaquin Local Health 11,11rict. 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 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 California." The applicant must call for all required inspections. Complete drawing on reverse side. �j Signed X _`�- Title: JAG 4.Q / ��/®g! 9�Z 6�8 g f Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area l Pit or Grout Inspection by Date r UeFinal Inspection by4�... Date r�r� fAdditional Comments: r ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 n} INFO AMOUNT DUE AMOl1NT(R�E(MMIITTED CASH RECEIVED BY DATE PERMn"NO. �.EH 13-24 rREV.,/K 51 - r atw EH.11-28 r '