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. rr 'ter•".'.s - - 7 N T '—l4 �.LY r rCs G✓.vC - . APPLICATION.FOR PERMIT -• C•fN-�••�L v�-cLced ell- SAN JOAOUIN LOCAL HEALTH DISTRICT 'for 5t4A 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466- 6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) lication is !. i I to construe and the Rules and Regulations of the San Joaquin ! Application is hereby made to the San County Ordinance LHealth ocal No.District549 for sewage or1No. 1862 for well//pumpt and/or stall the work hnd R described-bed. s app made in compliance with San Joaquin i Y >- I Local Health District: , M Size Lot Sze P ' i . '•: city 95i6i/ t Job Address --Z ..�/ S / ( j.KLc'RSJ�LI�.�I O .so a4 LctK4 /��O�l�t `I�ap Plf�e� Address i Owner's Name * '� -►f/�-7 L Phone t �. N e '' o� a— t at -License No. Address "SDESTRUCTION-� ,�( r Contractor - WELL FiFLACEMENT ❑ ~�^ OTHER (B"t TYPE OF WELLlPUM : WEL"L❑ SYSTEM REPAIR ❑ I�C r PUMP INSTALLATION ❑ S-o P DISPOSAL FLD. PROP. LINE I SEWER LINES —.-#1 pIT5 5LIMPS DISTANCE TO NEAREST: SEPTIC TANK �- AGRICULTURE WELL OTHER WELL YS :I FOUNDATION INTENDED USE TYPE OF:WELL PROBLEM ARF11 CONSTRUCTION SPECIFICATIONS Dia. of Well-Casing Open Bottom anteca Dia. of Well Excavation _ l ❑ Industrial Type of Casing S Specificationys I ❑ Gravel Pack ❑ Tracy Q/ Type o Grout ❑ Domestic/ ❑ Delta Depth of Grout Seal , r Public ❑ Other rox. Depth ❑ Eastern Surface Seal.lnstaled by ❑ Irrigation App tate Work Done ---j��--� Type of Pumper--- H.P.. 2 C r Repair Work Done F1TYP Sealing Material (top 50'1 P # Wel Destruction F, Weil Diameter Depth Filler Material (Below 50'I ermined if public sewer is available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ (No septic system N + Commercial f Other Installation will serve: Residence , Number of bedrooms Water table depth Number of living units: ; Character of soil to a depth of 3 feet: 1 Capacity—� No. Compartments C /Mfg G ' t. SEPTIC TANK ❑ Tye f Method�Disposal,.x^ j 2 PKG. TREATMENT PLT. ❑ Property Line ' ` r Foundation l Distance to nearest: Wel � Total length/size F --LEACHING LINE Gl No. &Length of lines WeiProperty Line FILTER BED-., L2 Distance to nearest: l Foundation I ` Size A �� Number 5£EPAGE PITS ❑ Depth ,. C- Property Line Foundation SUMPS [_1Distancei to nearest: Well + DISPOSAL PONDS ❑ ! I hereby certify that 1 have prepared this application and that the work wi� be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Ythat in the Home owner or licensed agent's signature certifies me subectlto workman'srtcompensation lawsofCalifornia.rnance of -Contractor'swork for 1hir ng'rr sub-contracting th, permit is issued, lsignlat not employ any person in such manner as to become 1 persons subject to workman's compensa- certifies the following:"I certify that in the performance of the work r which this permit is issued,I shall employ p tion laws of California." + applicant must cal for all required ins s. Complete drawing on reverse side. y The j Date: Title: • t Signed i OR DEPARTMENT USE ONLY p 3 d Date 4 r° Araa Q Application Accepted by Date Date Final Inspection by .: � Pit or Grout Inspection by . j` Additional Comments: - t ❑ Stk 466-6781 ❑ Lodi „369 3621 ❑ Manteca 823 7104 ❑ Tracy �` 5 Stk., CA 95201 Applicant - Return all copies to: Environmental Health Parmit/Services 1601 E. Hazelton Ave., P.O. Box 2 .._ qjRECEIVED BY' DATE PERMITNO. FEE AMOUNT DUE" AMOUNT REMIASH INFO EH 13-24(REV.1/H 51 EH 1426