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APPLICATION FOR PERMIT SAN-JOAQUIN LOCAL HEALTH DISTRICT (J 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 Cfi� PERMIT EXPIRES T 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. g i Jo b'Address )9.S "- ZE, City l S Lot Size r t� PM � Owner's Name-1 j 19 f�,�•� ap' � Address. ' fG /l#iC" G in Phone 't a n i Contractor ✓�CJ7 r° �AgSs A ` ►►+ License No.`��ott�' Phone3g F I_7K TYPE OF WELL/PUMP: NEW WELL K WELL REPLACEMENT ❑ ;;DESTRUCTION ❑, PUMP INSTALLATION SYSTEM REPAIR ❑ 1 OTHER ❑ _ - P DISTANCE TO NEAREST: SEPTIC'TANK /7•bAJr-- SEWER LINES ft,"V- DISP-OSAL'FLV,4b41-9� PROP. LINE FOUNDATION AGRICULTURE WELLA&Z45-__ OTHER �/__ PITS/SUMPS } WELL Uo-, � .INTENDED USE TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS ❑ Industrial ! Open Bottom ❑ Manteca Dia. of Well Excavation f�f" Dia. of Well Casing n Domestic/Private ❑ Gravel-Pack ❑ Tracy Type of Casing Specifications' fl Public r Other ❑ Delta Depth of Grout Seal b f) F'�' Type-of Grout I T Irri4atioon —..Approx. Depth Itif tasters Surface;Seai Installed by.--11 f/er- Repair Work Done ❑ Type of Pump H.P. _ State Work Done _---- - -""Well Destruction. ❑ Well Diameter Sealing,- terial-(top 50') Depth _ Filler Material (Below 50 7 _ TYPE OF SEPTIC WORK: NEW.INSTALLATION Ll REP_AIR/ I ADDITION € I DESTRUCTION ( Wo•septic system permitted if public sewer is "� available within 200,feet.j Installation will serve: Residence_ Commercial_ Other -- -- - -� Nu r of living units: Number of bedrooms 4EPTICharacter . ii to a depth of 3 feet: Water table depth C TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑- Method of Disposal Distance to nearest: Il' Foundation Pro.perty.Line ' 9 LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line l SEEPAGE PITS 11 (Depth Size Number SUMPS Cl Distance to nearest: Well Foundation 7 Property Line11 - DISPOSAL PONDS 0 . 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. i Home owner or licensed a`ent's signature certifies the following: } g g g: "I certify that in the performance of the work for which this permit is issued, 1 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 workforwhich this ermit is-issued,i shall employ m p persons subject to.workman's compensa- tion laws of California.” � ",'_--" The'applicant ust call for all required inspections. Complete drawing on reverse side, Signed Title: pate: -fQR DEPARTMENT USE ONLY Application Accepted byZI I AA_ Date I`� Area Pit or Grout Inspection by Dat Final Inspection b Dated Additional Comments: i w ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca .823-7104 D-Tracy 835-6385 Applicant- Return all copies.to: Environmental Health'Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009; Stk.,'CA 95201 INPEO MOUNT DUE AMOUNT.REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 1324 tREV,I i H sl L� tO� {` [/cam) g� ..EH 14.28 S 4 v �J V � " fi, -J- = , ��Sp i