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,..:�� .Mfr. � • • v-�*n`4 i � "llww//tr//��yy`lalJJ//�Jrr■ _ APPLICATION FOR PERMIT ►O s SAN JOAQUIN LOCAL HEALTH DISTRICT � 4 1601 E. HAZE T ON AVE., STOCKTON, CA (21fk , Telephone (209) 466-6781 Imo ` V , � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,(�ro. (Co lite lin Triplicate) �� o A p ice�tion is reby made to the San Joaquin Lo I�fealtistn�of ria p(+rfnit WAffruct 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. •y Job Addressf 3�� 4v7y,5T"f_Qe,6r City 1ftur-6644 Lot Size o; AC, PM 7� r Owner's Name _ILF"}� I Address Z 3 67 0-A-15 TRAL,5:7 PEO Phone Contractor's Name _04- 4i relac:� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ s:. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO !NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material-(top 50') (� Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.! ••.� Installation will serve: Residence_41 Commercial— Other Number of living units: _� Number of bedrooms_-.2 -- P Character of soil to a depth of 3 feet: 41VWater table depth SEPTIC: TANK ,Type/Mfg �• Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ? " .� "Distance to nearest: Well�� Foundation �_ Property Line :30'0c p LEACHING LINE No. & Length of lines _ 3- _ Total length/size FILTER BED ❑ Distance to nearest: Well d17 Foundation 20 Property Line SEEPAGE PITS ❑ Depth Size Number-' SUMP,) Distance to nearest: Well " Foundation Property Line DISPOSAL PONDS ❑ I 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 District. � . - F---.- 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 permit is issued, I shall employ persons subject to workman's compensa- tion lays of California." - The applicant must call f II re ired inspections. Complete drawing on reverse side. Signed Title: Date: �J l ; 'FOR DEPARTMENT USE ONLY Application Accepted by Data grow �/ Area yy Pit or Grout Inspection by Date ,Final Inspection by Date�� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant• Ratu n all copies to:frivironmental kiealtPermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED.; CASH,*- RECEIVED BY DATE PERMIT"N0.' +EH 13-24(REV.101831 EH 1426