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APPLJCATION FOR PERMIT t�'' SAN JOAQUIN LOCAL HEALTH DISTRICT SOS 1601 E. HAZEL T ON AVE., STOCKTON, CA �,Z.�tp1Z Telephone (209) 4666-6781 Qom. C9" PERMIT EXPIRES I-YEARFROM D �. $�,�� (Complete in T ' Application is heiebv made to the San Joaquin Luf Luca) Health District or � �'r tall the work herein described. This application is mace in campiiance with San Joaquin County<7rpinanca No.549 for ge or 18621fyy�umo and the Rules and Reguiations of the San Joaquin Local Hesirn District. , r Job Address 7= r'1;]Leland Cart G Lot Size X 1Wt PM Owner's Name ate- M 2EM .,.� Address 1.M W].IIf7W PSS Rdt_C=�f CA Phone 1-800-1+51-27% Contractor TnTest E3aarat Dri1Lylg Address 333 F'1.t ld St., Ra—do qMMlvt ' 554979 C573 -7276 Phone638--7276 TYPE OF WELL/PUMP: NEW WELL M WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 115 ft• SEWER LINES � �• DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL "• OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia.of Weil Casing 4 irch ❑ Domestic/Private 3&Grave) Pack ❑ Tracy Type of Casing EW Specifications In mom Mx&tori% In Other 0 Delta Depth of Grout Seal 21 a. Type of Groutoe t2b I I Irrigation U1 —Approx. Depth I 1 Eastern Surface Seal Installed by t73IiIIij.epdpa Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Oiamemr Searing Material (top 50') Depth Filler Material (Below ST) C TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AODITION I I DESTRUCTION I I IN*septic system permitted if public sewer is 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 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Oisposaf Distance to neaten Well Foundation Property Line LEACHING UNE ❑ No. b Length of fines Total length/size FILTER BED ❑ Distance to nearest•. Well Foundation Properly Lina SEEPAGE PITS I I Depth Sine Number SUMPS ❑ Distance to nearest: Wel( Foundation Property Line DISPOSAL PONOS ❑ I hereby certtty that I have prepared this application and that the work wiii be done in accordance with San Joaquin county ordinances, state laws, an nAn and regulations of the San Joaquin Local Health Oistr= Hare owner or licensed&gem's signature certifim Ate following: "I carsfy 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 Califomia."Contractors hiring or sub-contracanq 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. Signed X ( ,,•- Tide: Data: R DEPARTMENT USE ONLY �l /� / Application Accepted by C.C�nx� 4Oats -. t�` u A '7'a Pit or Grout inspection by ate Final Inspection by a Additional Comments: 4— C3 Stk 466-6781 ❑ Lodi 3ss-mi ❑ M ecs 823-7104 ❑ Traev 33S-6385 �jyLs Applicant- Return all copies to: Environmental Hoe" Permit/Services 1601 1- Hazelton Ave., P.O. Box 2009. Stk., CA 95201 FEE AMOUNT DUE AMouNT ReAnrTeo neva rt p BY OAT$ PF_RMW No. INFO �y . EM Isis teEv. s. �7 71 Gl kM r2i C� -